
Class 

Book 

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COPYRIGHT DEPOSIT. 



ORTHOPEDIC SURGERY 



THORNDIKE 



A MANUAL 




/ 

OF 


S2y 



ORTHOPEDIC SURGERY 



BY 

AUGUSTUS THORNDIKE, M. D. 

ASSISTANT IN ORTHOPEDICS AT THE HARVARD MEDICAL SCHOOL; VISITING SURGEON 

TO THE HOUSE OF THE GOOD SAMARITAN J ASSISTANT ORTHOPEDIC SURGEON TO 

THE CHILDREN'S HOSPITAL, BOSTON; FELLOW OF THE AMERICAN MEDICAL 

ASSOCIATION, THE AMERICAN ORTHOPEDIC ASSOCIATION, THE 

MASSACHUSETTS MEDICAL SOCIETY, ETC. 



WITH 191 ILLUSTRATIONS. 



PHILADELPHIA 

P. BLAKISTON'S SON & CO, 

1012 WALNUT STREET 

1907 












(LIBRARY of CONGRESS 

Iwu Conic u 

OCT !7 *90f 

Copy n eh! Entry 

CLaI^A xxc,no. 

COPY B. 



Copyright, 1907, by P. Blakiston's Son & Co. 



Printed by 

The Maple Press 

York, Pa. 



TO 

MY COLLEAGUES PAST AND 

PRESENT AT THE CHILDREN'S 

HOSPITAL AND ESPECIALLY 

TO 
MY TEACHERS AND FRIENDS, 

~£. TC. Bradford, ytir&. 

AND 

m. w. TLovett yar$., 

IN GRATEFUL ACKNOWLEDGMENT 

OF THEIR KINDNESS AND PATIENCE, 

THIS BOOK IS DEDICATED. 



PREFACE 

In this little book the attempt is made to present Orthopedic 
Surgery in a simple way to the student and practitioner by re-ar- 
ranging the subject so that the deformities which fall to the ortho- 
pedist are grouped both etiologically and chronologically. Part I 
comprises the ante-natal deformities, errors of development of the 
skeleton or of the nervous system, fetal bone diseases, accidents 
of birth like obstetrical paralysis or intracranial hemorrhage with 
spastic paralysis: Part II, deformities due to the action of external 
forces on growth, like weight-bearing, improper restraint from cloth- 
ing, unequal or asymmetrical muscular development as in flat-foot: 
Part III, the diseases and injuries of the bones and joints excepting 
those of the fetus: Part IV, deformities from acquired diseases of 
the nervous and muscular systems: Part V is a technical descrip- 
tion of the use of plaster-of-Paris, and of the way to make, fit and 
use some of the orthopedic appliances in vogue in this vicinity. 
While freely admitting the impossibility of an absolute classification 
of this sort because there are many deformities like coxa vara which 
arise from diverse causes, it is earnestly hoped that the student 
may be saved from confusing in his mind the identity of things 
essentially dissimilar like spondylitis and scoliosis, or congenital and 
acquired club-foot. 

The writer desires to express his thanks to his colleagues and 
others who have helped him, especially to Professors D wight and 
Bradford, of the Harvard Medical School, to Dr. Schulthess, of 
Zurich, Avhose exhaustive article on Scoliosis in Joachimsthals 
Handbuch der Orthopaedischen Chirurgie has been freely used, 
and to Dr. Max Bohm now of Berlin, likewise to Dr. R. W. 
Lovett, from whose book on Lateral Curvature a chapter is bor- 
rowed; and for aid in illustrating to Dr. A. W. George, radi- 
ographer to the Children's Hospital and of the Department of 
Anatomy. 

Augustus Thorndike. 
Boston, Massachusetts, 
September, 1907. 



I 
I 



CONTENTS. 



PART I 

Deformities Originating Before or During Birth. Malformations, 
Fetal Diseases. 

CHAPTER I 

Congenital deformities of the extremities. Greater defects; the 
ectromelian, i ; hemimelian, i ; phocomelian. Partial defects, 3 ; 
humerus, 3 ; ulna, 4 ; radius, 4 ; club-hand, 4 ; femur, 7 ; patella, 7 ; 
fibula, 8; tibia, 9. Parts of the foot. Supernumerary parts. 
Hypertrophy of a limb or part of a limb 1 

CHAPTER II 

Congenital deformities of the trunk. The spine, 12; thorax, 15; and 
pelvis. Numerical variations of the column, 12; their associa- 
tion with scoliosis. Other anatomical causes of curvatures, 16; 
the thorax and ribs, 18; the pelvis, 18; the clavicle and scapula. . 12 

CHAPTER III 

C Congenital luxations and subluxations : Club-foot, 25 ; cause, 25 ; fre- 
quency, 25; prognosis, 27; treatment, mechanical and operative.. 25 

CHAPTER IV 

Congenital dislocation of the hip, 38; frequency, 38; disability, 38; 
pathological anatomy, 40; symptoms, 43; signs, 44; diagnosis, 45; 
treatment, 47; manipulative reduction, 48; after-care, 51; Mueller's 
modification, 53; muscle-stretching machines, 53; Hoffa's manipu- 
lative reduction, 55; anterior transpositions, 57; cutting operations. 38 

CHAPTER V 
Congenital subluxations of the hip, 60; congenital dislocations and 
subluxations of the knee, 60; ankle, 62; shoulder, 62; elbow, 63; 
and wrist 60 

CHAPTER VI 

Fetal bone diseases, 65; syphilis, 65; tuberculosis, 65; rickets, 6^: osteo- 
genesis imperfecta, 66; chondrodystrophia fcetalis. Diseases of the 
nervous system of congenital origin, 69; spina bifida, 69; hereditary 
ataxia, 70; the dystrophies, 71 ; Erb's juvenile atrophy and paralysis, 
73; Landouzy-D6jerine type, 74; pseudomuscular hypertrophy. 
Those caused by an accident during birth, 74; Little's disease and 
obstetrical paralysis 65 



X CONTENTS. 

PART II 

Deformities Caused By the Influence of External Forces Acting 
Upon the Growth of the Skeleton. 

CHAPTER VII 

Irregularities of the skull, 85; gravity, 85; influence of defective sight or 
hearing on one side only, 87; lateral curvature of the spine, 87; 
frequency, 87; terminology, 88; normal curves at different ages, 89; 
pathological anatomy, 90; spine, 90; thorax, 93; pelvis?- Lateral 
curvatures of different parts of the spine, 96; simple and compli- 
cated, 102; causes, 104; congenital, 104; osteogenous, 105; me- 
chanic, 106; functional 85 

CHAPTER VIII 

Lateral curvature continued, 109; examining and recording scoliosis, 109; 
the normal movements of the spine, 112; treatment for malpostures 
and slight curvatures by exercise, 113; exercises in general 109 

CHAPTER IX 

Lateral curvature concluded, 132; treatment of structural scoliosis, 132; 
exercises for flexibility, 132; corrective jackets, 134; exercises for self- 
correction, 136; those for strengthening the trunk to maintain erect 
position, 137; Wullstein's jackets and braces, 137 ; operation of Hoke. 
Malpostures and their prevention, 138; school desks, 139. Round 
shoulders, 140; normal attitude, 140; round back, 140; hollow-round 
back, 140; forward shoulders, 141; the recording of antero-posterior 
curves and the attitude in standing. Funnel chest 132 



CHAPTER X 



Coxa vara, 145; congenital, 145; from bone diseases, 145; rickets, 145; 
trauma, 147; from growth, 145; diagnosis and treatment. Coxa 
valga, 149; from growth, 149; paralysis, 149; rickets, 149; osteomye- 
litis, 149; congenital dislocation of hip, 149; in amputation stumps, 
149; treatment in plaster bandages, 150; by operation. Acquired 
curves of long bones, 150; from growth, 150; femur, 151 ; knock-knee, 
152; bow-leg, 152; back knee, 152. Deformities of the foot from the 
influence of external forces, 153; hollow or contracted foot, 153; 
flat-foot, 156; congenital, 156; traumatic, 156; paralytic, 156; and 
static, 156; mechanics, 157; diagnosis, 158; treatment, 159; rigid 
flat-foot from sprain, 161; metatarsalgia, 162; cause and treat- 
ment, 164; painful foot from exostoses and bursitis, 164; policeman's 
heel, 165; hallux valgus, 165; hallux varus, 167; hammer toe 145 

PART III 

Affections of Bones and Joints. 
CHAPTER XI 

General considerations for study. Trauma and repair of bones and 
joints. True inflammations from microorganisms in bones, 173; 
joints and periarticular structures. Affections due to nutritional 
disturbances or autointoxications. Functional joint disease 171 



CONTENTS. XI 



CHAPTER XII 






Injury and repair. Bone, 179; subperiosteal hemorrhages, 179; bone 
growth from torn periosteum, 1 79 ; avulsion of the tubercle of the 
tibia, 179; superficial necrosis from trauma, 180; fractures. Joints, 
180; fractures, 180; dislocations, 180; sprains. Acute synovitis from 
sprain, 180; dislocations of the semilunar cartilages ,180; treatment, 
183; villous proliferation of the synovial membrane, 183; its causes, 
184; and results, 184; lipoma arborescens, etc., 184; treatment, 185; 
hemorrhages into joints, 185 ; in hemophilia and fractures into joints, 
185; appearance, 186; deformity, 186; results, 187; and treatment.. 179 

CHAPTER XIII 

True inflammations from microorganisms, 188; acute, 188; subacute and 
chronic, 189; periostitis, 188; actinomycosis, 189; osteomyelitis. 
Acute osteomyelitis, 190; its frequency, 191; age, 191; origin, 191 ; 
symptoms, 191; treatment, 192; usual seat in the shaft, 191; osteo- 
myelitis of the epiphysis, 191; acute arthritis of infancy, 191 ; course 
and treatment. Osteomyelitis after typhoid fever and after measles. 
Joints. Septic arthritis, 195; microorganisms, 196; source of infec- 
tion, 196; changes in the joints, 196; treatment. Forms differen- 
tiated from septic arthritis, 197; rheumatic fever, 197; acute arthritis 
of infants, 197; arthritis in the course of typhoid fever, 198; scarlet 
fever, 198; pneumonia, 199; gonorrhoea 188 

CHAPTER XIV 

Chronic inflammations of bones and joints. Syphilis, 203; inherited and 
acquired. Infantile syphilis, 203 ; osteochondritis, 203 ; separation of 
the epiphysis, 203; suppurative arthritis, 204; pseudoparalysis, 204; 
craniotabes, 204; syphilis of little children's bones, 204; dactylitis, 
204; periostitis, 205 ; enlargement of the epiphysis, 205; in older chil- 
dren eburnation, 205; bow-leg, 205; chronic serous synovitis, 205; 
pathology, 205 ; diagnosis, 206 ; acquired syphilis, 207 ; the spine, 207 ; 
the tibia. Tuberculosis. Vertebral tuberculosis, 207; pathological 
anatomy, 208; symptoms, 210; physical signs, 211 ; complications, 
212; abscess and paralysis, 214; diagnosis, 217; prognosis, 217; treat- 
ment, general and local, 217; recumbency, 219; ambulatory treat- 
ment, 223; care of complications. Tuberculosis in or around the 
sacro-iliac joint, 226; diagnosis and treatment 203 

CHAPTER XV 

Tuberculosis of the hip, 230; frequency, 230; pathological anatomy, 230; 
clinical course, 233 ; physical examination, 235 ; differential diagnosis, 
237; prognosis, 239; treatment; general and local, 239; recumbency 
and traction, 241; traction splints, 243; fixation splints, 243; plaster 
bandage, 243 ; correction of deformity, 243 ; osteotomy, 244 ; double 
hip disease, 245; abscess in hip disease, its treatment, 246; early 
removal of diseased foci of tuberculous bone, 246; excision of the 
hip, 247 ; amputation 230 

CHAPTER XVI 

Tuberculosis in and around other joints. Knee, 250; symptoms, 251; di- 
agnosis, 253; course, 252; prognosis, 253; treatment, general and local, 



Xll CONTENTS. 

254; conservative treatment, 255; early removal of foci in bone, 255; 
drainage, 256; resection, 256; arthrectomy, 256; abscess, 256; conser- 
vative and operative correction of deformity, 258. Ankle: Path- 
ology, 260; symptoms and signs, 261; diagnosis, 261 ; prognosis, 
262; treatment, 262; abscess, 262; excision of tarsal bones, 262; ex- 
cision of ankle. Shoulder: Symptoms, 264; treatment by ex- 
cision and amputation. Elbow: Symptoms, 265; prognosis, 265; 
general treatment, 265; excisions, 266; results. Wrist: Symptoms, 
267; diagnosis, 267; treatment, 267; excision and partial excision. 
Passive hyperemia for treatment of tuberculous joints and sin- 
uses 250 

CHAPTER XVII 

Affections caused by nutritional disturbance of the skeleton, 284; the 
nervous system or the general system. Scurvy of infancy, 270; sub- 
periosteal hemorrhages, 270; symptoms and course, 271 ; pathological 
appearances, 270; scurvy in the spine. Rickets, 272; age affected, 272; 
frequency, 272; pathology, 272; deformities, 273; coxa vara, 273; 
bow-legs, 273; knock-knees, 273; diagnosis, 276; treatment, 276; 
bow-leg, 276; knock-knee, 279; general treatment, 281; operations, 
osteotomy ,281 ; osteoclasis, 283 ; epiphyseolysis, 281 ; splints, 282 ; de- 
formities of the arms and treatment, 284; spontaneous fractures in 
rickets. Osteomalacia, 284; pathology, 285; the spine in osteo- 
malacia. Ostitis deformans, 287; frequency, 287; age, 287; symp- 
toms, 287; pathology and treatment. Secondary hypertrophic os- 
teoarthropathy, 288; appearance and occurrence. Acromegaly. Its 
three clinical forms. Charcot's disease or tabetic joint disease, 289; 
occurrence, 289; symptoms, 289; diagnosis, 289; the spine, 290; hip, 
290; and knee, 289; treatment. Arthritis deformans, 290; the atro- 
phic and the hypertrophic forms, 291; symptoms and course of 
atrophic form, 291; treatment, 291: symptoms and course of the hy- 
pertrophic form, 292; the spine in the hypertrophic form, 293 treat- 
ment, 293; Still's disease, course, symptoms, lack of pathological 
material, 293; treatment. Gout, 294; acute and chronic, 295; atyp- 
ical gout, 295; course and symptoms, 296; ulcerated tophi, 296; re- 
semblance of some chronic cases to arthritis deformans. Func- 
tional joint disease, 297; simulated and neuromimetic, 297; differen- 
tiation from true hip disease, 297; tumor albus, 297; club-foot, 298; 
paralysis, 298; the spine in neurasthenia 270 

PART IV. 

Acquired Diseases of the Nervous and Muscular Systems 
with Deformities. 

CHAPTER XVIII 

Infantile paralysis, 303; sporadic and epidemic, 304; pathology, 304; 
symptoms, 305; deformities, 306; disabilities and sequelae, 308; sco- 
liosis, 308; dislocations, 309; treatment for paralysis and deform- 
ity, 310; walking apparatus, 311; appliances to correct deformities, 
312; surgical measures to correct malpositions, 313; to transfer 
muscle attachments, 315; to restore control and power by nerve 
grafts, 320; to correct flexions, 313; to stiffen flail joints, 314; 
tenodesis and arthrodesis 3°3 



CONTENTS. Xlll 

CHAPTER XIX 

Diseases of the muscles, 323; torticollis, 323; varieties, 323; congenital, 
323; spasmodic, 323; symptomatic, 324; transitory, 325; dermat- 
ogenous, 325; acquired, 325; diagnosis, 325; treatment, 325; stretch- 
ing, 325; division of the sternomastoid, 326; plaster for after-treat- 
ment, 327; apparatus. Myositis ossificans, 327; two types, progres- 
sive and simple, 328; latter of two sorts irritative and traumatic 
which is often combined with osteomata growing from bone, 328; 
clinical characters, 328; age of onset, 328; treatment, 329; method of 
removal 323 

PART V 

Plaster Bandages and Orthopedic Apparatus. 
CHAPTER XX 

Plaster-of-Paris, 330; plaster bandages, how made, 331; applied, 331; re- 
moved. Plaster jacket for Pott's disease, 7,^^; applied recumbent, 
334; hammock frame, 334; Goldthwait's frame, 337; Lovett's frame, 
338; appliance for vertical traction and correction, the kyphotome, 
339. The plaster bed for Pott's disease. Plaster jackets for lateral 
curvature, 339; jackets for support and mild correction, how applied 
on the hammock frame, 340; corrective jackets on the Adams frame. 
Removable plaster jackets, 340; casts and removable jackets of 
leather, 340; celluloid, etc, 341 ; how made and fitted. Plaster jack- 
ets for resistant round shoulders. Plaster bandages for club-foot. 
Wolff's method of correction by stages. Plaster spica bandage for 
hip disease, 345; and for general use. How to apply them for con- 
genital hip after reduction. Plaster casts of the trunk and of the 
foot. Casts for flat-foot plates 330 

CHAPTER XXI 

Molded leather splints and jackets. The modified Taylor back brace 
for Pott's disease. Head supports for same, the oval ring, 353; the 
wire chin rest, 354; Goldthwait's head support. 355; the Thomas' 
collar, 357 ; modified head support for torticollis. The quadrilateral 
brace of Dane, 358; writer's modification of the back brace. Braces 
for lateral curvature, 362; Keen's modification of Dollinger's brace, 
363; Wullstein's brace. Hip splints, 364; traction hip splint and its 
modifications, 365 ; convalescent splint, 367; with knee-joint, etc., 36Q; 
Dane's hip splint, 369; the abduction hip splint, 371; Thomas' splint 
for fixation of the hip. Thomas' knee splint, 373; the caliper splint. 
Fixation splint for the ankle. Knock-knee irons, 377; bow-leg irons, 
378; Dane's bow-leg irons, 379; adaptation of the caliper splint for 
toe-drop and calcaneus, 380; other infantile paralysis splints, 381; 
the valgus shoe, 382; the equinus shoe, ^8^; the club-foot shoe. 
Flat-foot plates 349 



Index 



389 






L 



I 



ORTHOPEDIC SURGERY. 



CHAPTER I. 



MALFORMATIONS OF THE LIMBS. 

Congenital human deformities are so various that the author can- 
not here describe all of the varieties; selected examples must suffice 
instead of a detailed complete list. The student must not be sur- 
prised to meet at the clinic congenital deformities which are not 
described here, but should store in his mind, from his study of the 
examples, certain typical classes into which malformations fall 
and from which they may vary. He should strive by careful ob- 
servation to study each individual case so as to recognize the true 
nature of the deformity and to evolve independently of his teacher 
something to restore the function of the limb or lessen the disability. 

Many congenital deformities shorten life to a few days or weeks or 
are found in the still-born, such as anencephalus, rachischisis, etc.; 
others, like spina bifida, are often curable; the latter is considered in 
works on general surgery and is therefore omitted. 



TOTAL DEFECTS. 

Absence or extensive malformation of the extremities is not fatal 
but is very disabling for when both the arms and legs are lack- 
ing it is obviously impossible to supply the deficiency. A total 
deficiency of all four members occurs but rarely and produces great 
helplessness. The term ectromelian designates a person with com- 
plete absence of one or more limbs; hemimelian, one without the 
terminal portion of a limb or limbs, without hand or foot; phoco- 
melian, one whose much shortened limb bears a hand or foot close 
to the trunk like the flipper of a seal. These are the result either 



ORTHOPEDIC SURGERY. 



of lack of development, or of amputation in ntero; only the phoco- 
melian necessarily represents lack of growth, the other two may 
arise either because they failed to form or because they grew and 
were cut off. Non-formation of a limb must be due to some process 
beginning before the fourth week of embryonic existence, for the 
limbs appear about that time. Congenital 
amputations are of later origin — the earliest 
one recorded showed the remains of a foot 
corresponding to that of a ten weeks fetus. 
A limb is amputated either by tight en- 
circling coils of umbilical cord or by so- 
called amniotic bands forming a constriction 
around it. An amniotic band is a string-like 
structure connecting the skin of the fetus 
with a point on the amniotic lining of the 
fetal membranes. When these bands are 
present at birth, some sort of congenital 
malformation is generally present. 

ABSENCE OF ONE PAIR OF EXTREMITIES. 

When one pair of limbs is absent, the 
helplessness is less; absence of both legs 
may give rise to but little inactivity, for 
artificial limbs or any serviceable rigid sup- 
port may be used with crutches, and little 
ones soon learn to walk on their hands. 

Absence of the arms is more disabling, 
but one often finds useful fingers or a partly 
formed hand near the shoulder as in the accompanying photograph. 
(Fig. 3.) This boy, with his fingers, could write with pencil or pen 
and do a variety of things which he learned at the public school; he 
also learned at the Industrial School for Cripples to typewrite with 
his toes, to draw on the blackboard with them, and to use his feet for 
hands in many ways. 

In Denmark, Norway and Finland, special schools for cripples 
exist w r here ingenious machines and contrivances are used to take 




Fr i. 1. — Fetus with 
congenita] amputations. 
(Cast in the Warren 
Museum.) 



MALFORMATIONS OF THE LIMBS. 



the place of hands. Handless cripples are taught to weave cloth, 
to make brushes, baskets, and shoes, using the tongue and teeth 
principally. Some women even embroider with the teeth and the 
toes may be trained to great usefulness. For many years a hand- 
less artist was seen in the art gallery 
at Antwerp painting pictures with 
his feet. Boston, New York, and 
Philadelphia now give industrial 
training to cripples. 

Artificial hands and arms are 
made lighter and more serviceable 
than they used to be, but their field 
of usefulness is limited. 

Less disabling are the deficiencies 
of one or more of the long bones of 
the limbs; these partial defects may 
occur ;n one, two, or even four ex- 
tremities. For instance, a woman 
in Germany has the following mal- 
formations: the left upper extrem- 
ity consists of an upper arm bear- 
ing a single finger; the right arm is 
a tapering stump, containing half 
of the humerus; the left leg lacks 
the femur and the fibula; the right 
is a rounded stump, containing 
two short bones bearing a small 
foot, of which the heel, sole, and 
two toes are present. With the 
help of special artificial legs and arm she can write, knit, wash, 
partly dress herself, and feed herself with fork, knife, and spoon; she 
walks easily, keeps busy and enjoys life. 




Fig 2. — Fetus with absent right lower 
extremity. (Warren Museum.) 






PARTIAL DEFECTS OF THE UPPER EXTREMITY. 

Club-hand. — Absence or defect of the radius or ulna pro- 
duces club-hand, a term which designates a deviation of the hand 



ORTHOPEDIC SURGERY. 



at the wrist from its alignment with the forearm; a lateral devia- 
tion means a congenital deficiency of the radius or ulna — the hand 
turns to the side of the missing or defective bone. Congenital dis- 
placements of the hand in extension or flexion may be called club- 
hand and this kind is not associated with bony defect, but with 
some other cause, such as early developed paralysis. Club-hands 




Fig. 3. — Armless boy typewriting. {Industrial School jor crippled 
and deformed children.) 



like club-feet have been described by adjectives, which define 
the direction of the malposition, such as palmar, dorsal, radial 
and ulnar club-hand, radio-palmar, radio-dorsal, ulno-palmar, and 
ulno-dorsal club-hand. Radio-palmar is the common type, with the 
ulna usually strongly bowed inward and the hand pointing at right 
angles to or somewhat up the arm. Deficiency of the ulna is rare, 



MALFORMATIONS OF THE LIMBS. 



5 



and all elbow motion is lost if the ulna be absent; only part of 
the carpus is developed and the little and fourth fingers are often 
lacking. One finds the thumb missing with most defects of the 
radius. The changes in the articular facets and the formation of the 
wrist bones are analogous to those in congenital club-foot. Kir- 
misson describes curious anomalies of the muscles of the forearm. 
Treatment. — Mild club-hands, especially in little babies, are 
treated by gentle manipulations, bandaging to a light splint, or 
the child is etherized, and the hand held by a plaster bandage in an 




Fig. 4. — Cast of radiopalmar club hand. ^Warren Museum.) 



overcorrected position gained after forcible stretching. One treated 
this way for a year, at the Children's Hospital, had the hand firmly 
grown into a normal position at the end of that time. A small tin 
splint was used six months longer as a precaution. Three years 
later, the child had a good, straight, useful hand. In older children, 
whenever the difficulty of reduction demands it, tenotomies or tendon 



6 ORTHOPEDIC SURGERY, 

transferences may be tried, or shortening and lengthening of cer- 
tain tendons. When there is only one bone in the lower forearm, 
especially if it be crooked, osteotomy and retention for a long time 
in a plaster bandage has given excellent results in a few cases. The 
after treatment demands careful muscle training and massage. The 
following bone operations have been performed on rebellious cases: 
cuneiform osteotomy of the ulna, by Thompson; suture to the semi- 
lunar bone of the split styloid process of the ulna, by McCurdy; 




Fig. 5. — Bones of same. (Warren Museum.) 



the removal of two carpal bones and fastening the end of the 
ulna into the hole in the middle of the wrist, by Sayre; wedging the 
carpus into the split open end of the ulna, by Bardenheur; Kirmisson 
aims at a stiff wrist, for he regards instability of the hand after 
operation as the most serious obstacle to its utility. Operations 
for muscle transference have been little tried so far. 



MALFORMATIONS OF THE LIMBS. 7 

PARTIAL DEFECTS OF THE LOWER EXTREMITIES. 

The femur is far more often defective than absent. According 
to Reiner, there may be (i) a congenital coxa vara with the shaft 
and the femoral neck short and crooked; or (2) the femur may be 
divided into two different parts, the head and trochanters forming 
the upper portion, while the distal end articulates both with it and 
with a fairly normal knee-joint; or (3) in extreme cases, only the 
head, neck and trochanters exist with a small remnant of the 
distal end of the femur growing on top of the tibia without knee- 
joint. Reiner considers all these conditions are due to the same 
sort of maldevelopment. The modelling action of the muscles 
determines the amount of crookedness of the femur. These de- 
formities of the femur are 
often associated with absence 
of the fibula, the patella, or 
part of the foot, and produce 
much shortening of the leg. 

A young woman who has 
been under the writer's care 
for several years with a short- 
ened leg of this sort, walks 
with ease, using an artificial 
limb designed by Gibney, of FlG " 6 -- Absent or tard >' Patella - 
New York, which takes advantage of the flexed position of her hip 
and knee and offers a broad shelf on which the under surface of the 
thigh rests and the body-weight is supported. She is better off with 
this apparatus than she would be with an amputation stump and 
an ordinary artificial limb. 

Absence of the patella is infrequent. In a baby, one cannot 
tell if the patella will form later or not; doubtless, many a case 
of tardy development has been reported as absence of the pa- 
tella. This bone should appear as a cartilaginous deposit in the 
third month of fetal life, and ossification begins between the ages 
of four and seven years and should be completed at puberty. The 
defect may be double or single, and the sexes are equally affected. 




8 ORTHOPEDIC SURGERY. 

Other malformations were found in half the cases in literature. 
Ankylosis of the knee associated with defective femur is not in- 
frequent; general laxity of the knee may be present, or a subluxation; 
sometimes the tendon of the quadriceps is inserted into the joint 
capsule instead of into the tubercle of the tibia. Unless these mal- 
formations accompany the deformity, the prognosis for a useful 
limb is good. While children they fall easily and are unsteady, in 
later life there is little disability and the gait satisfactory. Some 
are easily tired, totter a little, go down stairs cautiously, fearing a 
fall; others are not impeded in any way. 

Treatment. — Surgical skill cannot make a patella grow. In lax 
knees prevention of abnormal movements in the joint does good, 
for by restricting side movements, the knee ligaments in a child 
soon tighten and the joint regains its utility. A serviceable ap- 
pliance for this purpose consists of a light double upright splint 
with a hinge joint at the knee so arranged as to allow less than the 
normal amount of flexion and extension. Where a faulty attach- 
ment of the quadriceps tendon into the joint capsule occurs (a rare 
condition) it might be transplanted into the tubercle of the tibia, by 
an operation. 

Absence or Defect of the Fibula. — The fibula is deficient more 
often than the tibia but both conditions are uncommon. When 
this malformation exists, the foot is always displaced. It is more 
common for the fibula to be absent completely or for the upper part 
of the bone to be present. In the foot, the little toe, or the little 
and fourth toes may be absent with their metatarsals. The tibia 
is rarely straight and it may bend sharply, suggesting the so-called 
intra-uterine fracture. The misplaced foot rolls out in valgus, 
sometimes in equino-valgus, and there may be an upward dis- 
placement of the foot at the ankle — a condition which has been 
described as congenital dislocation of the ankle. Left without 
treatment, great shortening and atrophy always occur. 

Treatment. — Treatment aims to hold the foot in a good posi- 
tion to walk on, either by mechanical means, by a surgical operation, 
or by both methods combined. The problem is not unlike that 
which is presented after destruction of the fibula by osteomyelitis. 



MALFORMATIONS OF THE LIMBS. Q 

Francke, of Brunswick, Germany, in order to compensate for the 
shortening which usually takes place after three or four years, re- 
sected the ankle-joint and fastened the os calcis to the tibia in the 
position of extreme equinus. He placed the articular surface of 
the tibia against the upper surface of the calcis behind the astragalus 
and refreshed the astragalus and the front of the tibia to secure 
bony union between them. For temporary fixation he drove a 
long steel nail through the sole of the foot, the os calcis and lower 
epiphysis of tibia, removing the nail in three weeks. The result 
two years afterward was excellent, and there was no tendency to 
valgus. 

Curving of the tibia may be remedied by osteotomy, overcorrection 
and immobilizing in plaster. Tenotomies or muscle transferences, 
may prevent a return of valgus, but, so far, a mechanical support, or 
a valgus shoe (Chapter XXI) and a high sole have to be employed 
unless union is obtained between the foot and the tibia, as in 
Francke's case. 

Congenital Deficiencies of the Tibia. — These are often bilateral. 
Myers, of New York, found 46 cases in literature, 11 of which 
were observed in the fetus or new-born. It is often considered 
hopeless to use the limb for walking, and of the reported cases 6 
had been amputated. The bone was absent 43 times in 34 children; 
defective 22 times in 12 children. Twice as many boys as girls had 
the deformity, and other deformities were present in 80 percent of the 
cases. 

Treatment. — Many, however, have operated to restore func- 
tional use of the limb. In little children, they have opened the knee- 
joint, trimmed the head of the fibula and transplanted it into the 
intercondyloid notch or into a hole bored in the external condyle, 
straightening the foot at the same operation by tenotomies. Myers 
did this and then he opened the ankle-joint, cut off the external 
malleolus, denuded the articular surface of the astragalus, and sutured 
the fibula firmly to its center by coarse absorbable catgut suture. 
He kept the foot in a moderate equinus position in plaster for six 
months, and allowed the boy to walk upon it in plaster eight weeks 
after operation. Later on, a double upright steel splint with a 



ORTHOPEDIC SURGERY. 



waist-band and perineal straps was worn, which was jointed at the 
ankle, knee, and hip; the knee-joint could be straightened and 
fixed and had a leather knee cap. The perineal straps were soon 
discarded and a cork sole was added to the boot to equalize the 
length of the limbs. A year afterward, he walked all day, had 

gained muscle power, so that he could 
flex the knee to a right angle and 
straighten it perfectly. 

Deficiencies of the Skeleton of the 
Foot. — Several of these defects may 
come in connection with deficiencies 
of the tibia and fibula. The inner 
side is defective with a malformed 
tibia, the outer with the fibula. These 
deformities may also occur independ- 
ently. Absence of a toe usually gives 
no trouble, but extreme defects of 
the foot demand mechanical support 
or amputation. Once in a while one 
sees the skeleton reduced like that in 
the illustration. This boy was bereft, in both feet, of all his bones 
except the os calcis, one metatarsal, and the phalanges of a single 
toe. Amputation and two artificial legs now enable him to walk 
and run almost as well as anybody. 




Fig. 7. — Malformation of the 
foot. (Warren Museum.) 



EXTRA LIMBS. 



Supernumerary Deformities. — The occurrence of supernumerary 
limbs has been explained by the inclusion of part of a twin, they are 
rare except in the side-show of the circus. Supernumerary fingers 
and toes are, however, a frequent occurrence and are usually am- 
putated early in babyhood. Their treatment and that of web 
fingers is found in all works on general surgery. Extra bones are 
sometimes formed in the wrist and ankle which have more interest 
for anatomists than for clinicians. With increasing use of the 
X-ray, they may, however, be mistaken for fractures and dislo- 



MALFORMATIONS OF THE LIMBS. 



II 



cations, and it is probable that their presence alters the statics of 
the foot in a way not yet understood. 



CONGENITAL HYPERTROPHIES. 



Hypertrophies of Limbs or Parts of Limbs. — One-half the body 
may outstrip the other (unilateral hypertrophy), or a limb may 




Fig. 8. — Cast of a hand showing hypertrophy of finger (Warren Museum.) 



grow much faster than its mate, or one finger may grow as in this 
cast of a hand. 



CHAPTER II. 

CONGENITAL DEFORMITIES OF THE TRUNK; SPINE, 
PELVIS, THORAX AND SHOULDER-GIRDLE. 

THE SPINE. 

Until lately malformations of the spine were limited in the minds 
of most student to spina bifida; other deformities were considered 
unimportant. If a baby had a lateral curvature it was attributed 
to carrying the child on one arm or to fetal rickets. Very rarely was 
a congenital deformity of the thorax recognized, but with the use 
of the X-ray malformations are now becoming more common and 
the occurrence of a form of congenital scoliosis is now generally 
conceded. Some, like Whitman, have palpated and detected the 
absence of a lumbar vertebra and demonstrated it by the X-ray. 

Numerical Variations in the Spine. — Numerical variations in 
the different spinal regions have been attracting the attention of the 
anatomists: in the Warren Museum at the Harvard Medical School 
there is a collection of fifty-two spines showing numerical variations 
collected from the dissecting room by Prof. Dwight. These varia- 
tions come from the persistence in the whole spine or in part of it 
of a greater or a smaller number of vertebrae than the number which 
is usual, 33 or 34, (for the embryo at one period has about 40). 

The average normal spine has 7 cervical, 12 dorsal, 5 lumbar, 
5 sacral and 4 or 5 coccygeal vertebras. The occurrence of 8 cer- 
vical vertebrae is very rare, but a spine with six cervical vertebrae is 
not uncommon; it is also not unusual for the seventh and some- 
times for the sixth cervical vetebrae to have ribs which are called 
cervical ribs. The development of the twelfth rib is very variable; 
sometimes it is rudimentary or absent, or well developed but short; 
at other times it is quite long;. and when a cervical rib exists the thir- 
teenth rib below is usually wanting or rudimentary and the vertebra 



CONGENITAL DEFORMITIES OF THE TRUNK. 



i3 




Fig. 9. — Numerical variation with scoliosis from Dwight collection, Warren 
Museum. Thirteen pairs of ribs, that on the left is smaller and on the same side 
the twenty-fifth vertebra is sacral, on the right lumbar. Left lumbar scoliosis. 



14 ORTHOPEDIC SURGERY. 

may in shape resemble a lumbar more than a dorsal one. At other 
times one finds the twentieth vertebra, normally the first lumbar, 
with a long straight transverse process like a rib or bearing a true 
rib. The tw r enty-fifth vertebra, normally the first sacral, may be 
a free lumbar vertebra or it may be the second instead of the first 
of the sacral series. In the long and the short backs there seems 
to be a differing number of vertebrae and at times the pelvis and 
thorax may approach or get away from the head by one or two 
vertebra?, Bohm's variation in a cranial or caudal direction. The 
right and left side of the column may both be affected by this varia- 
bility, or only one side may vary; and the latter seems to be a com- 
mon thing to happen. Sometimes the atlas fuses with the skull on 
one side and behaves as a part of this variation. 

Relation of Scoliosis to Numerical Variations of the Spine. — 
In what way does this spinal abnormality affect the mechanics of the 
spine ? Do the unilateral museum specimens show any scoliotic spines 
among the number? Bohm found that several were evidently 
scoliotic r but it is possible to make any spine seem scoliotic in mount- 
ing a ligamentous specimen for the museum; therefore this should 
be established and verified on the living. So he had the patients 
with lateral curvature at the Massachusetts General Hospital Out 
Patient Department X-rayed. 

By taking a number of small negatives of the spine and piecing 
the prints together he could produce a picture of the whole spine; 
the cervical spine was taken with the head turned to one side to get 
rid of the shadow of the chin. On this he could count the bodies, 
the transverse and spinous processes, and the ribs; for minute de- 
tails of structure he studied negatives. He X-rayed all patients 
with lateral curvature who had no history of preceding empy- 
ema, paralysis or rickets, and of these 26 out of 31 showed evidence 
of numerical variation of the spine. So far this has not been con- 
firmed or denied by the experience of others. 

Anatomical Causes of Deformity in Different Parts of the 
Spine. — The mechanics of the deformity vary in different parts of the 
spine. The abnormal vertebrae are always on the borderline where 
two spinal regions join, so that one has not far to look for them. At 



CONGENITAL DEFORMITIES OF THE TRUNK. 



15 




Fig. 10.— Kypho-scoliotic spine from the Dvvight collection in the Warren 
Museum; with the following numerical variations, 7 cerv. vertebrae, 13 dorsal, 
and 6 lumbar; fusion of several vertebral bodies and of the three first ribs on 
the left, bicipital first ribs, the twenty-sixth vertebra is sacral on the right and 
lumbar on the left side; marked left lumbar-dorsal kyphoscoliosis. Note the 
amesial pelvis, the right side is small and the wing of the ilium flares less. 



i 



l6 ORTHOPEDIC SURGERY. 

the sacro-lumbar junction one finds a vertebra which on one side 
is sacral and on the other lumbar, that means that one transverse 
process expands into a portion of the wing of the sacrum and the 
other is free; in these (not uncommon in museums), the top of the 
body always inclines and by its obliquity tips the spine out of the 
vertical; they resemble the wedge-shaped vertebrae of scoliosis (p. 
90). At the dorso-lumbar border one may find that a vertebra has 
below on one side the articular process of the dorsal type and on 
the other side one of the lumbar type, but that they articulate with 
two lumbar-type joints and this tips the column above out of 
the vertical and inclines it to one side. At the cervico-dorsal border 
on one side there is a well-grown cervical rib articulating on the sternum 
just above the insertion of the rib from the first dorsal vertebra, 
which, however, is long and slender like a second rib and comes 
opposite to a normal short first rib on the unaffected side; the effect 
of two ribs of unequal length is to twist the spine by rotating the 
bodies of the first dorsal and last cervical away from the side of the 
long rib producing both a twist and a lateral curve. 

These variations have been studied by Dwight and Bohm on the 
spines in the museum and have been demonstrated in the X-rays. 
All of the patients, however, developed no perceptible curve before 
puberty, so that, granting that they are in origin abnormalities 
of development, the subsequent growth of the spine must play an 
important share in their production. 

Congenital Scoliosis. — The study of congenital scoliosis is receiv- 
ing more and more attention the world over. Schulthess, who has 
just compiled for the "Handlurch der Orthopadischen Chirurgie 
of Joachimsthal" the most complete account of all forms of lateral 
curvature, says. " of late years examples of it have become so common 
in medical literature that one can no longer regard congenital sco- 
liosis as a rarity, and we believe that when the cases of scoliosis re- 
ceive a more careful anatomical examination, a large proportion 
will be transferred to the category of the congenital class." He refers 
to the presence of a half sacral lumbar vertebra, and to the occur- 
rence of scoliosis with cervical ribs, with congenital elevation of 
the scapula, both single and double, and to its occurrence with 



CONGENITAL DEFORMITIES OF THE TRUNK. 



17 




Fig. 11. — Scoliosis, on top of the sacrum is apparently a half vertebra possi- 
bly an extreme wedge-vertebra, center of column obscured by heart and liver. 
{Children' 1 's Hospital, A. W. George, Radiographer.) 
2 



A 



1 8 ORTHOPEDIC SURGERY. 

spina bifida. Athanassow collected thirty-one cases of presumably 
congenital scoliosis, partly from his own observations, partly 
from literature. Schulthess also refers to two patients with con- 
genital kyphosis and to one described by Bernhard, a baby born 
with a kyphos from the second to the seventh dorsal which later 
developed into a lateral curvature with marked rotary deformity. 
He divides congenital scoliosis into two groups, those which develop 
about puberty and those whose deformity is seen soon after birth. 

Drehmann, at the Congress of the German Society for Orthopedic- 
Surgery, in 1906, showed the X-rays of the dorsal and lower cervical 
spine of seven patients with cervical ribs and scoliosis, in which 
he could trace many curious defects, not only in the vertebral bodies 
which were often partly split in the median line, (an anterior spina 
bifida deformity), and sometimes consisted only of a rudimentary 
half vertebra, but also in the ribs which were often fused together 
for part of their length. The illustration (Fig. 11) shows either an 
extreme wedge-vertebra or a half-body of a lumbar vertebra in 
a boy with congenital scoliosis at the Children's Hospital. 

The appearance of children with cervical ribs varies, some show 
little abnormality and a slight lateral curve of the spine, others are 
considerably deformed. 

PELVIS. 
Congenital Deformities of the Pelvis. — They often are due 
to the sacrum which is malformed in much the same way at 
other vertebrae are in congenital scoliosis, and produces a de- 
formity known as the oblique pelvis of lateral curvature. It has 
been studied by obstetricians as it is considerable of an obstacle 
to the birth of a child. As one looks down on such a pelvis one 
sacral wing seems much larger than the other and the oblique diam- 
eters of the pelvis are quite unequal. Sometimes the right or the 
left half of the pelvis grows larger than the other side and we then 
have the amesial pelvis. 

THORAX. 
Congenital Deformities of the Thorax. — The congenital scoliosis 
which is seen in infants is often associated with malformations of 



CONGENITAL DEFORMITIES OF THE TRUNK. 



19 



the ribs, the fused ribs, the two headed ribs, the defective or absent 
ribs. All these may be present, and at times the thorax is much 
deformed, while at other times the deformity is only appreciated 
after an X-ray has shown its existence. (Figures 12, 13 and 14.) 

Treatment. — The treatment of these deformities of the spine, 
thorax and pelvis offers little hope of amelioration. The pro- 





Fig. 12. — Congenital deformity of 
thorax, scoliosis, Sprcngel's deformity 
of scapula. (Children's Hospital.) 



Fig. 13. — Same child as in Fig. 12. 
Absent ribs produce the furrow be- 
low left nipple. 



longed use of braces is of value, because by them the deformity 
is prevented from increasing and the general attitude and carriage 
of the child improves with time and growth sometimes more than 
was expected. This is true of a little boy and girl now at the Chil- 
dren's Hospital. "As the twig's inclined the tree will grow." An 
infant should be kept lying as long as possible, not allowed to crawl 



20 



ORTHOPEDIC SURGERY. 



or walk, and when it does begin, it should have a well fitted cellu- 
loid jacket or brace which should be worn almost constantly. Simple 
exercises may be begun early, including breathings. The apparatus 




Fig. 14. — Radiograph of Figs. 12 and 13. 



should be^rnodified from time to time or refitted to allow for growth ; 
sometimes a head support is needed, but at all times the apparatus 
should be arranged to allow free play to respiration. 



CONGENITAL DEFORMITIES OF THE TRUNK. 21 

THE SHOULDER-GIRDLE. 

Total deficiency of the shoulder-girdle has been observed with 
absence of the arm. 

The Clavicle. — Defects of the clavicles are rare. They may 
be absent or partly defective, usually the latter, trilateral defects 
may produce lateral curvature. Kappeler saw a double total defect 
of the clavicles. The patient could walk on her hands although 
when she sat down her shoulders could be made to touch in front of 
the sternum. Sherman recently reported two cases, and Marie four. 
While young, patients have comparatively little disability, but the 
usefulness of the arms may be considerably restricted in adult life. 
The deformity is inconspicuous and sometimes has been discovered 
purely by accident. It may be inherited. 

Treatment. — Usually nothing is done for it. Sherman ad- 
vises, if the arm is seriously disabled, that the scapula be attached 
to a piece split off from the first, second and third ribs, so that the 
shoulder will remain fixed in a proper position to give a useful arm. 

Congenital Elevation of the Scapula. — Sprengel's deformity; 
Hochstand des Schulterblattes; Sprengelsche Deformitate. 

This defect is rare; but ioo cases have been reported since Sprengel 
described it in 1891; about 8 of these were double. The causation 
is unknown but several theories exist. Rager says that the scapula 
develops in the neck and fails to move down to its proper place. 

The whole scapula is always raised but the degree and the amount 
of rotation vary considerably in different cases; it is often turned, 
about the shoulder-joint as an axis, so that the outer border looks 
downward, and the upper border and the spine of the scapula are 
crowded into the supraclavicular space, making a great prominence 
at the root of the neck. It may also turn so that its lower angle 
lies close to the spines, and the outer border is nearly horizontal; 
or it may lie so that the entire posterior border is widely separated 
from the spine, the plane of the shoulder-blade being sagittal in- 
stead of frontal and the shoulder well forward; again, the upper 
angle of the scapula may lie close to the spine and be attached there 
by an extra bone; this bone sometimes connects the transverse proc- 






ORTHOPEDIC SURGERY. 



ess of the seventh cervical vetebra with the base of the spine of the 
scapula and some have guessed that it might be an extra rib out of 
place. Lateral curvature of the spine accompanies unilateral cases 
and some of the bilateral ones. 

^Eight cases of double deformity have been recorded, all with 
typical high shoulder-blades, which in one case were considered 
a family characteristic. Scapulae may be misshapen, somewhat 

small, and their position varies 
in the same way that unilateral 
deformities do. Owing to the 
slight range of motion of the 
shoulder-blade, motions of the 
shoulder-joint are somewhat re- 
stricted. The neck is sometimes 
very short and thick, so that the 
occiput comes near the seventh 

k cervical spinous process and the 

chin to the notch of the sternum. 
Whether the short neck comes 
from an increased curvature of 
the cervical spine, from fused, or 
absent vertebrae, one cannot tell, 
for, on account of the short 
neck, the X-ray picture is ob- 
scured by the shadow of the 

chin. Spina bifida and spina 

Fig. is. — Congenital elevation of , . £ i ■>, , - , 

scapula. {Children's Hospital.) blfida occulta have accompanied 

it. Bony distortions of the scap- 
ula without displacement have occurred in rickets; they have also 
been attributed to constant pressure from the clothing affecting the 
growth of a normal young child's bones. 

Treatment. — There are two forms in vogue, gymnastic and 
mechanical, and operative, and they may be combined. Gymnastic 
exercises include very forcible stretchings, and wearing a brace to 
hold the shoulders back and down; it may accomplish considerable 
correction if presevered in for over a year. Most cases, however, 




CONGENITAL DEFORMITIES OF THE TRUNK. 2$ 

require operation, and this mobilizing of the scapula should be 
preparatory to it. 

Operation. — Three different conditions may confront the opera- 
tor: shortened and fibrous muscles, a permanent bending of the 
upper part of the scapula, and a bony attachment between the scap- 
ula and spine. An X-ray is to be studied before operating. 

If the elevation be due to short muscles, they are in part 
fibrous and sometimes fatty, a condition analogous to the sterno- 
mastoid in congenital torticollis. The contracted muscles are in- 
serted along the posterior margin of the scapula and the angles at 
each end of it. The incision, about six inches long, should, there- 
fore, extend over its posterior border, at least, from the top of the 
scapula to the angle below; the attachment of the trapezius is first 
exposed and divided, then the two rhomboid muscles and the levator 
anguli scapulae; the scapula may then be turned with its posterior 
border backward and the serratus magnus divided, after which it 
may be brought down into place unless the distorted anterior sur- 
face of the scapula refuses to remain on the comparatively flat sur- 
face which the chest wall presents. 

A similar but a longer incision is needed in those cases where 
the upper portion of the scapula above the spine bends forward at 
right angles with the rest of the bone, or where a large exostosis forms 
on the upper and inner corner; after exposing the anterior surface 
of the scapula by dividing the serratus magnus and the other muscles 
already alluded to, the bent portion — that is the entire upper and 
inner corner of the scapula and a good part of the bony supraspinous 
fossa — is cut away with bone cutting forceps. 

In the remaining class, where the scapula is attached by an extra 
bone or cartilage to the spinal column, the whole bony attachment 
should be excised and all muscles and fasciae sufficiently divided 
to replace it in its proper position. The muscles and fasciae are 
united by absorbable catgut sutures, layer by layer, and the skin 
sutured without drainage. After the operation, the shoulder should 
be put up in a sterile dressing with a plaster-of-Paris shoulder ban- 
dage, or this may be incorporated into a plaster jacket with the 
whole shoulder covered in. By means of a window in the jacket, 



24 ORTHOPEDIC SURGERY. 

the dressings may be changed when necessary, but the new position 
should be immovably maintained at least three weeks. 

The results of operation have not been brilliant; some ameliora- 
tion of the deformity is usual, and an improvement in the use of the 
arm, but rarely has a complete and permanent restoration of sym- 
metry resulted. Some advise the operation for children only, but 
one very successful result has followed operation on an adult patient. 

For the scoliosis and the joint stiffness after operation, well-se- 
lected gymnastic exercises are indicated, see Chap. VIII, page 114. 



k 



CHAPTER III. 

CONGENITAL LUXATIONS AND SUBLUXATIONS. 

CONGENITAL CLUB-FOOT OR SUBLUXATION OF 
THE TARSUS. 

Cause of Congenital Club-foot. — Many different theories have 
been advanced to explain just how club-foot arises; Bessel-Hagen 
divided congenital club-foot into two classes, a small class arising 
from non-development of the bones, and a large class including all 
others. Other groups might be made, for instance, those due to 
congenital paraylsis either from spina bifida or cerebral palsy. It 
is simpler to study club-feet in the old way, to divide them into 
two groups, the congenital and the acquired, including among 
the latter deformities paralyses which began before or at birth. 
It is also simpler to acknowledge that no theory of the etiology 
has so far remained unchallenged, that the cause is wrapped in 
obscurity. A history of inherited club-foot is not uncommon. 

Different Sorts of Deformity. — The abnormal position in which 
the foot is held varies, hence different terms are used to designate 
them : equinus, varus, calcaneus, valgus, meaning respectively toe down, 
toe in, toe up, and toe out; also any combination of these like equino- 
varus, and calcaneo-valgus, meaning down and in, up and out, etc. 
Pes cavus, hollow foot, designates a contraction of the plantar fascia 
and tendons. Pes planus, flat foot, is not often congenital. 

Frequency. — Talipes equino-varus is the only common form of 
congenital club-foot, hence unless otherwise specified club-foot means 
that form. Both acquired and congenital club-foot are common; it 
has been noted as infrequently as once in 1903, and as often as 
once in 630 births; the variation may be due to one compiler count- 
ing only severe cases of equino-varus. Out of 213 cases of club- 
foot collected by Roberts, from the records of the New York Or- 
thopedic Hospital and the Orthopedic Dispensary of the University 

25 



26 



ORTHOPEDIC SURGERY. 



of Pennsylvania, 5 were equinus, 3 calcaneus, 73 varus, 29 valgus, 
95 equino-varus, 3 equino-valgus, and 5 calcaneo-valgus, that is 
almost four out of five show a well-defined inward rotation and ad- 
duction of the fore foot upon the ankle. Simple calcaneus and 
calcaneo-valgus in infancy are also common in a mild degree and 
may be disregarded, as they are soon outgrown; only the severer 
cases persist and require attention. Almost all congenital club- 
feet are therefore of the 
varus or equino-varus 
type. 

Diagnosis. — Diagno- 
sis is often evident at a 
glance, and the history 
discriminates between 
the congenital and the 
acquired. Differences 
there are in the degree 
of deformity and the 
amount of atrophy. For 
ease of description the 
deformity is classed as 
slight, moderate, and 
severe; or first, second, 
and third degree; with 
reference to treatment 
the age and difficulty to 
reduction should also be 
taken in account : at the 
Children's Hospital in Boston they are more often spoken of as in- 
fantile, walking, resistant, relapsed, and neglected cases. 

Disability. — The gait in walking and running is peculiar, especially 
in equino-varus feet where the toes point at each other and are lifted 
over each other in walking, hence the name reel foot. Large callouses 
form on the weight-bearing surface wherever it may be and still further 
change the normal outline of the foot. In rare cases walking gives 
pain; the writer once saw a young woman who had never been out 




Fig. 16. — Congenital club foot, talipes equino- 
varus. {Children' s Hospital.) 



CONGENITAL LUXATIONS AND SUBLUXATIONS. 



27 



of the house for that reason; correction of the deformity has en- 
abled her to walk in comfort, so this symptom in no way contra- 
indicates straightening the foot. 

Prognosis. — The prognosis is excellent if overcorrection be once 
obtained and if the after-treatment maintains the foot in the over-cor- 
rected position until not only the muscles, fasciae, and ligaments, but the 
small bones and joints grow into and adapt themselves to the new 
position. Once this is done there should be no relapses. Un- 
fortunately some relapses still occur, but they are preventable, and 
remediable. The surgeon should 
remember that "half cures are no 
cures," that if the perfect position, 
or one with a slight calcaneo- valgus 
be secured and maintained long 
enough, all will be well; but that 
relapsed cases are hard to correct. 
Very rarely has there been a death 
from club-foot correction. Ampu- 
tation should only be advised for 
those whose club-foot is dependent 
on great bony deficiency in both the leg and foot. 

Treatment simply aims to overcorrect the distortion and to main- 
tain a straightened position till relapse is impossible. Rectification 
may be by manipulation, correction in plaster bandage, apparatus, 
and by the operative methods, tenotomy, division of the ligaments, 
mechanical forcible correction, open incision, osteotomy and removal 
of a wedge of bone, astragalectomy. Retention afterward is first by 
plaster bandage, later by apparatus. Correction, or rather overcor- 
rection, must be complete; with such a choice of methods, if complete 
overcorrection is not obtained by one method the surgeon should go on 
and try another and another until it has been accomplished. As a 
rule infantile club-foot in the first three months can be cured by sim- 
ple straightening applied by the mother's or nurse's hand three times 
a day, or if more unyielding by plaster-of-Paris bandages. Plaster 
bandages should include the toes and the knee, semi-flexed to 
prevent the bandage twisting so as to allow a return of the varus 





Fig. 17.- — Severe grade club feet. 



ORTHOPEDIC SURGERY. 



position. The skin beneath the plaster is protected from pressure 
by thick layers of cotton batting, and in order to protect the ban- 
dage from soaking up urine from the diaper shellac or paraffin is 
painted on from the top half way down the leg. It is best to re- 
new the plaster bandage at rather frequent intervals on account of 
this. Correction by plaster bandages is, in the writer's opinion, 
preferable to apparatus for babies who cannot walk; if appara- 
tus is wanted there are special splints for babies which have value; 

the tin shoe though old fashioned is 
easy to make and apply. A paper 
pattern is first cut to cover the sole and 
rise along the inner border of the foot 
from the tip of the great toe to a point 
just below and behind the inner mal- 
leolus; from this pattern a tin sole- 
piece is cut, bent to a right angle where 
the inner border and sole join; a wire 
upright is soldered on rising to a point 
half way between the ankle and knee, 
crossing to the outer side and ending 
at the trochanter in a pad; the sharp 
edges of the tin are covered with ad- 
hesive plaster, the upright is thickly 
wound with cotton flannel, the sole 
plate padded with felt; the splint is 
applied by first bandaging the foot to 
the sole plate without regard to the 
position of the upright, then bringing 
the upright into place and holding it there with another bandage. 
For older babies the Taylor club-foot shoe may be similarly 
used in a simplified form, substituting a stiff bandage for straps 
and buckles and making the upright without a joint at the 
ankle, and in order to evert the foot extending the upright to the 
waist, where it ends in a T-shaped plate jointed to the upright over 
the trochanter with the horizontal arms ending in a strap and 
buckle at the anterior and the posterior spines of the ilium respec- 




Fig. 18. — Relapsed club foot. 



CONGENITAL LUXATIONS AND SUBLUXATIONS. 20 

tively. Babies' feet are too small to be held by straps to a sole 
plate. When correction of deformity is the object the tin split, or 
Taylor shoe, should be reapplied at short intervals by the surgeon, 
who from time to time bends the upright to obtain better position 
as the deformity slowly yields; used for retention only it may be 
seen less frequently by the surgeon. 

Operative Treatment. — An infant is never too young to begin 
corrective treatment; as a rule the earlier the easier, yet there are 
some feet which refuse to yield to manual correction or simple cor- 
rective apparatus. Under anesthesia these may be overcorrected by 
using stretching force, applied either with the hand or wrench, or 
by tenotomy, subcutaneous division of ligaments, open division of all 
resisting parts. Bone operations are unnecessary before the age of 
walking. 

Tenotomy and Fasciotomy. — Tenotomy, or subcutaneous divi- 
sion of tendon, requires a special little knife called a tenotome; those 
on the market are too large as a rule, both the sharp and blunt 
pointed; a single sharp pointed tenotome is enough for all tenoto- 
mies; the cutting edge should be one-quarter inch long and the ex- 
treme width at the base one-eighth of an inch, no more. A stout 
round shank one inch long and an eighth of an inch in diameter 
joins it to the handle. Fascia and ligaments are divided in the same 
way as tendons. 

The tendons most commonly divided for equino-varus are the 
tibialis anticus, tibialis posticus, and the tendo Achillis, but every 
tendon is within easy reach in the foot, and may require division. 
Anaesthesia is not always employed for tenotomy in England, here 
it is the rule. 

Tenotomy of the tendo Achillis is done with the patient lying on 
the side; an assitant grasps the fore foot so as to make the tendon 
tense, the operator enters the tenotome through the skin to the side 
ojghe tendon, about half way between the heel and the muscular belly 
of the gastrocnemius, passes the point to the remote side flat on the 
tendon, then turns the cutting edge towards it and with slight to- 
af^RYo movements divides the tendon across. The forefinger of 
the operators other hand pressing over the back of the knife 



30 ORTHOPEDIC SURGERY. 

assures him of its whereabouts. Division must be complete, the 
gap between the severed ends at least a finger's breadth wide; one 
judges of this by pressing the finger into the gap where any small 
undivided tendinous bands may be felt and tenotomied. Imme- 
diate fixation in a plaster bandage should follow, with a small pad of 
sterile gauze or cotton over the puncture. Bleeding is disregarded, 
unless sufficient to imply puncture of a large artery like the pos- 
terior tibial. Elevation of the limb or pressure often stops the 
bleeding, or in cases of doubt immediate operation for ligature may 
be done. With the knowledge obtained from his forefinger of the 
position of the knife's point, the surgeon runs almost no risk of 
wounding anything unintentionally. 

The tibialis anticus tendon is felt so plainly when on the stretch 
that it is only necessary to make it tense, enter the knife and cut 
nothing but tendon; tenotomy is much safer below the annular 
ligament, where the position of the dorsalis pedis may be verified 
by palpation. 

The tibialis posticus tendon is less easy to reach. The point often 
selected is on a line half way between the posterior border of tibia 
and the inner side of tendo Achillis the width of the thumb above 
the maleolus' tip; the tenotome is directed straight in for half an 
inch, then the point is swept in toward the tibia while the foot is 
forcibly abducted to put the tendon on the stretch. The danger 
is lest one cut the posterior tibial artery. Puncture of this artery 
has produced a small aneurism which later needed ligation; hence 
some surgeons prefer an open incision. 

The tibialis posticus tendon is more safely reached from a point 
immediately in front of the inner malleolus in the baby's foot, and 
in the adult, a finger's breadth in front of it. By directing the teno- 
tome inward and downward the surgeon reaches the inferior as- 
tragalo-scaphoid ligament and opens the astragalo-scaphoid joint, 
dividing, at the same time, the posterior tibial tendon as it passes 
beneath the bones. From the same incision the insertion of the 
tibialis anticus muscle to the tubercle of the scaphoid is easily 
reached and the astragalo-scaphoid joint is freely opened laterally. 
In correcting club-foot by tenotomies the tendo Achillis is preserved 



CONGENITAL LUXATIONS AND SUBLUXATIONS. 3 1 

till the varus position has been overcorrected, for it gives a solid 
ankle on which the fore foot can be manipulated, as all firmness is 
lost when it is cut. After tenotomy forcible stretching to gain bet- 
ter position is used with the hand or Thomas wrench. 

Fasciotomy of the plantar fascia is needed in more than half of the 
operable feet. A complete division may be made by entering the 
tenotome on the inner side of the sole one-third of the distance from 
the heel to the ball of the foot, pushing the point just under the skin 
as far as the outer border of the foot and cutting upwards freely 
while the assistant pressing on the ball of the foot and toes makes 
it tense; as band after band gives way the fore foot yields with a 
slight noise. After dividing deeply all the way across the foot the 
surgeon feels with his finger for more bands of fascia to tenotomise 
giving to the foot as much dorsi-flexion as he can. Another 
method is to stretch and cut all tight bands in the sole wherever 
they are felt, instead of dividing the whole width of the fascia. Re- 
lapsed cases may require a second or third fasciotomy; repeating the 
operation is without ill effect. All tenotomies, fasciotomies, and sub- 
cutaneous cutting should be performed with strict asepsis and pro- 
tected from infection for a fortnight. 

Division of ligaments is at times necessary in infants and is 
frequently to be performed on comparatively mild looking club-feet 
in walking children. The astragalo-scaphoid ligament is reached 
from a point between the tubercle of the scaphoid and the an- 
terior corner of the maleolus; the joint can be first made out by pal- 
pation and the knife cutting towards the joint divides the upper and 
inner fibres, then the lower and inner ones. It sometimes happens 
that free cutting away of this ligament will release the deformity 
so much that section of the tibial tendons becomes needless. The 
operation is done subcutaneously with the tenotome. 

The calcaneo-cuboid ligament should also be divided in cases 
with much deformity. The joint can be felt in a thin patient a 
short ways back of the prominence of the proximal end of the fifth 
metatarsal bone. A sharp-pointed tenotome is used, dividing every- 
thing to the bone and striving to cut into the joint and to divide the 
whole ligament. 



2,2 ORTHOPEDIC SURGERY. 

The after-treatment is overcorrection in plaster bandage for 

two or three months; then a club-foot brace and plenty of walking on 

it for eight months or two years or long enough to grow straight joints 

and a muscular development which will maintain the new rather 

than the old position. This takes years, and it is hard to tell when 

this has been attained; apparatus should therefore be continued 

too long rather than too short a time and be left off gradually. Daily 

manipulation by the parents and rubbing are of the greatest value 

while apparatus is in use and are the best safeguards against atrophy 

and stiffness. 

Mechanical Appliances. — Retention apparatus for walking 

children should allow the greatest amount of freedom consistent 

with the prevention of a return to the deformed position. There 

are many splints and devices 

to correct club-foot. At the 

end of the book (Chap. 

XXI), will be found the 

description of one which has 

been used for some time in 

the Children's Hospital. 

Great care must be used by 

the parents in applying ap- 
Fig. iq. — Manual correction of varus, „„ „i„„ ~-~~~ 1 „„ :+ *- 

club-foot. paratus properly as it too 

often happens that relapse 
may be traced to such neglect. Careful oversight must be main- 
tained during the first months of treatment so as to instruct and to 
watch the efficiency of the apparatus. Except for the very mildest 
club-feet, in walking children corrective apparatus has been dis- 
carded in favor of operations because the length of treatment is 
much greater when apparatus alone is relied on. 

Forcible Correction Under Anaesthesia. — Forcible manual 
correction has been strongly advocated by Lorenz, of Vienna, 
for both walking children and for neglected cases; the chief 
advantage over other operations lies in the fact that all parts of 
the foot participate in the correction instead of a limited portion, 
as in osteotomy, or removal of a wedge-shaped piece of tarsus. 




CONGENITAL LUXATIONS AND SUBLUXATIONS. $3 

This method, rapid manual correction, is no more curative than 
any other and requires precisely the same prolonged after-care until 
all danger of relapse is passed. Under ether the inward position 
of the fore foot is first overcome by grasping the heel in one hand 
so that the thenar eminence is on the cuboid and affords a fulcrum 
on which the other hand may bend the fore foot outward by a se- 
ries of increasing pressures and relaxations, until it is completely 
stretched and motion in that direction is a little more free than in 
a normal foot; if greater force is needed than the hands alone can 
give, the triangular block of wood is used as a fulcrum, the heel and 
inner border of the fore foot are pressed on with the hands. After 
all resistance is overcome in this direction the ankle is grasped and 
the foot twisted to bring the outer border higher than the inner, 
the direction of the twist being outward-and-upward and the force 
is applied on the sole beneath the cuboid to prevent its dropping 
down in the sole. No rigidity or elastic recoil to the deformity 
should remain now except that from the short tend'o Achillis and 
the plantar fascia. To stretch it, simple dorsi-flexion is employed, 
with the child lying face down, the knee flexed at a right angle; the 
operator hooks two fingers about the tips of the heel, pressing down 
with the ball of the hand on the ball of the foot and toes, while the 
ankle is steadied with the other hand; it is essential that the tendo 
Achillis be intact to offer resistance. Finally if it refuses to stretch, 
as it may do, the tendo Achillis is tenotomized, and sometimes the 
posterior fibres of the ankle-joint too; the foot should hang perfectly 
limp and the toes almost touch the front of the shin when the stretch- 
ing is finished. The first plasters extend from beyond the tips of 
the toes to the upper third of the thigh with the knee flexed and 
with a very heavy sole of plaster re-enforced with wood to walk 
on. Great care is used in holding the foot overcorrected during 
the setting of the plaster. On the next day but one they, Lorenz's 
patients, begin to stand and walk, in order that the weight of the 
body may still further stretch and correct the deformity. Whitman 
changes the plaster bandage in a month and allows the free use 
of the knee from then on. At three months he substitutes a light 
brace worn inside the shoe. With this is added massage of the 
3 



34 



ORTHOPEDIC SURGERY. 



whole leg and foot and passive movements twice a day to carry 
the foot as far in all directions as it went at the end of the oper- 
ation. 

Wolff's Method. — Rapid manual correction with less force and 
with an imperfect immediate rectification has been advocated by 
Wolff, of Berlin; after an incomplete correction of deformity he ap- 
plies a plaster-of-Paris bandage, and three or four days later cuts it 
around the ankle, removes a wedge-like piece from the outer side of 
his cut, crowds the edges together, and holds what he gains with a 
few turns of fresh plaster bandage. Larger and larger sections are 
removed every few days until complete overcorrection is reached. 
Then by covering the bandage with shavings, cloth, and glue it may 

so strengthen that it may be worn 
six months or a year without change. 
Club-Foot Wrenches. — Several 
different forms of wrench have been 
used to correct the deformity of 
club-foot. The Thomas wrench is 
in general favor and has stood the 
test of time. Its use is readily un- 
derstood from the illustration (Fig. 
21). A more scientific instrument 
has been devised by Bradford; 
McKenzie, of Toronto has more 
recently described his wrench, and 
there are many others. Personal 
experience has led the writer to return to the use of a wrench after 
abandoning it for several years. 

Phelps' Method. — The method of correction by free open incision 
was advanced by Phelps. It has the advantage of facility and al- 
lows the inspection of every step taken. The incision is made from 
the tip of the inner malleolus to the middle of the sole, or it may be 
made along the line of the first metatarsal; all contracted tissues are 
divided in plain sight including ligaments; the artery and nerve are 
isolated and preserved; after completing the operation the foot should 
hang limp without returning to the deformed position. Partial sut- 




FlG. 20. — Corrected club foot held 
in overcorrected position at end of 
operation, ready for plaster bandage. 



CONGENITAL LUXATIONS AND SUBLUXATIONS. 



35 



n- l> 



ure of the skin is desirable for there is some danger of relapse from 
the slow contraction of this large mass of scar tissue. 

Operations on the Bones. — Osteotomies and resection of bones 
are of use principally for the neglected and the relapsed cases; the 
surgeon prefers milder methods because he avoids correcting one de- 
formity by producing another, which is what all bone operations 
on the foot do; nevertheless the principle should be adhered to of 
doing everything necessary to secure a straight foot. The altered 
plane of the astragalo-scaphoid joint and that of the 
cuboid and calcis offer at times an insuperable obstacle 
to any other method of treatment. 

Since there is great change in many club-feet in the 
obliquity of the neck of the astragalus and in the direc- 
tion of its articular facet, it must often be osteotomied 
to rectify the deformity. In the baby or young child 
whose astragalus is cartilaginous, one may pull the scaph- 
oid into place and hold it there long enough for slow 
adaptation to take place by growth, but it is hard to see 
how perfect adaptation can come later in life if there 
be great change of the direction of the astragalus' 
neck. Osteotomy of the neck is only done after a 
thorough stretching and dividing of all short tissues; the 
incision is from the tip of the malleolus to the inner side of the proximal 
end of the first metatarsal; it is a short incision and reveals the tibialis 
anticus tendon close to its insertion; using it is a guide, the astragalo- 
scaphoid ligament is divided, which allows the scaphoid to slip for- 
ward and expose the neck of the astragalus for chiseling; some- 
times it is better to remove a bit of the neck or even the entire head 
of the astragalus, in which case the plane of the cut makes a great 
difference; it should be at right angles to the axis of the foot and 
must look upwards as well as forwards so as not to impede dorsal 
flexion. The subsequent treatment does not differ from that for a 
tenotomized club-foot, only the skin is sutured and the first plaster 
is worn six weeks undisturbed if a catgut suture is used. 

Osteotomy of the anterior portion of the os calcis is indicated where 
there is great prominence of the foot's outer border which fails to 



Fig. 21. 

Thomas' 
wrench. 



36 ORTHOPEDIC SURGERY. 

reduce under all other means; like the distorted astragalus neck 
it may straighten by growing in a young child whose bones are 
still soft and cartilaginous, but if ossification be complete it is 
more apt to force the cuboid down into the sole of the foot so as to 
gain room for itself. This dropped cuboid is a very painful thing 
to walk upon. To prevent it the removal of a large wedge of bone 
just behind the anterior articular surface of the calcis has been 
satisfactory. If, after tenotomies, division of ligaments, and for- 
cible correction under ether with wrenches, this part of the deformity 
be still unyielding, a curved incision is made on the outer border of 




Fig. 22. — Result of astragal ectomy. (X-ray from Children's Hospital.) 

the foot from the tip of the malleolus to the point of greatest outward 
prominence, exposing the peronei tendons and the periosteum; they 
may be retracted or divided and the osteotome is entered into the outer 
side^ of the os calcis a quarter of an inch back of the cubo-calcaneal 
joint and parallel to it; after severing this end of the bone the osteo- 
tome again divides it at least a finger's breadth further back in a 
plane looking forward and outward, and the intervening wedge of 
bone is removed; the shelf-like sustentaculum tali offers considerable 
resistance to complete division and has to be fractured after partly 
dividing it. When the fore foot swings and the cut surfaces of cal- 



CONGENITAL LUXATIONS AND SUBLUXATIONS. 37 

cis are brought together one must see whether overcorrection has 
been really achieved; if not the removal of another slice will often 
suffice. If the perinei tendons were cut they should be sutured 
again and shortened. The skin may be redundant and it is a good 
plan to cut off some of the excess; a small drain may be left to allow 
for oozing from the bone and to be removed in a few days; dress- 
ings are done through a window in the plaster bandage without 
disturbing the position of the foot. 

Combined Operations. — These operations are at times combined 
with good effect. Sometimes the malleoli give insufficient room for 
the anterior part of the body of astragalus which is always wider; 
this prevents dorsi-flexion or else the external lateral ligaments of the 
ankle tear and stretch and the fibula stays too far back, in other 
words there is a partial dislocation of the foot forward on the leg at 
the ankle. Whitman describes an operation he calls malleotomy for 
the correction of this condition. After dividing the contracted tissues 
at the back of the ankle, he cuts the ligaments through an anterior 
vertical incision and pries the malleolus out with a thin chisel in- 
serted between it and the astragalus, suturing the ligaments after 
replacing the astragalus. 

Many different sorts of resections and enucleations of bones 
have been tried and abandoned; cuneiform resection of the tarsus 
is done less and less on account of resulting shortening and stiff- 
ness, although the end results have generally afforded serviceable 
feet for walking. With so many resources at the surgeon's command 
it should never be said that a congenital club-foot is incurable. 



CHAPTER IV. 

CONGENITAL DISLOCATIONS: HIP, KNEE, PATELLA, 
ANKLE, SHOULDER, ELBOW, WRIST. 

CONGENITAL DISLOCATION OF THE HIP. 

Congenital dislocation of the hip is not very rare. Out of 332 
dissections of the hip-joint at the Hospital des Enfants Trouves, 
Parise found it three times. In this country it exists more often 
than once in two thousand births. About eighty-five percent are 
girls and fifteen boys; no reason is known for it. It is also a little 
more frequent on the left side, but the double cases may be almost 
as common. 

Sometimes it is found luxated in the fetus, and again it is only 
dislocated when the child begins to walk, or later on by a fall or 
slight violence. It is supposedly due to a perverted growth of the 
bones. Some attribute it to a spontaneous dislocation from paral- 
ysis or bone disease in the fetus, but the evidence of these con- 
ditions is entirely wanting; violence at birth is not a direct cause, 
but may act to dislodge an already insecure joint. Jackson Clark 
considers that continued flexion of the hip produces it; a firm con- 
traction of the anterior portion of the capsule has been demonstrated 
by him in an eighth month fetus. The undeveloped state of the 
acetabulum may be due to displacement of the head early in fetal 
life; if the head of the femur does not lie in its socket, the socket 
does not grow properly. But after all one only knows that the 
cause is congenital. 

Disability. — In little children the disability is slight, the limp be- 
comes gradually noticeable and sometimes, in double congenital dislo- 
cation, it is distressing by the time three years is reached; double dis- 
locations do not limp, they waddle. The older and heavier one is the 
more annoying the lameness, but except in a few instances disability 

*8 



CONGENITAL DISLOCATIONS. 



39 



from double dislocation does not prevent walking till middle life 
or old age. Adults with a single dislocation may be unable to 
undertake steady active work, and may suffer from attacks of pain 
or from muscular cramps which subside under rest. Obesity and 
feebleness are the things to dread, although crutches prolong the 
activities of life. Muscular patients suffer less than weaklings; 
double dislocations are more disabling than single; those whose 





Fig. 23. — Single dislocation. 



Fig. 24. — Double congenital 
dislocation, broad perineum and 
prominent trochanters. 



dislocated head rests above or in front of the socket have less dis- 
ability; the general trend is to remain stationary or to grow worse 
slowly. Such is the life history of the untreated and of the failures. 
Little by little surgical skill has found ways of bringing about per- 
manent reduction and cure, and although the proportion of failures 
is considerable it grows steadily less. 

Froelich, of Nancy, however, reports two exceptional cases of 



4o 



ORTHOPEDIC SURGERY. 



spontaneous cure of congenital dislocation of the hip. They were 
double dislocations and X-rays were taken before and after the cure. 
Pathological Anatomy. — Much attention has been given to 
the study of pathological specimens and considerable variation 
exists. In the fetus or the infant who has not crept, the dis- 
placement is naturally less than in those who have walked. The 
capsule becomes lengthened by stretching from carrying the 
body-weight as if it were the strap of the old fashioned C spring 
on a carriage, the fixed point being the upper part of the 
femoral insertion near the trochanter, and the movable end the 
pelvic attachment. Part of the capsule rising from the lower 





Fig. 25. — On the right the capsule is stretched as in a dislocation on the 
dorsum ilii, on the left one sees how drawing down the hip may fold the cap- 
sule in front of the head. 



part of acetabulum forms a covering of dense tissue right 
across it, shutting it off from the rest of the joint cavity except 
for a small opening at the side or rear; this opening between the 
acetabulum and the cavity around the end of the femur is often 
too small to let the head pass through, and too unyielding to be 
stretched by it post-mortem, and has been called the " hour-glass 
constriction of the capsule." Lorenz found a way by which he 
can often pass the femoral head through it. When the constriction 
obstructs the passage of the head, the portion between it and the pel- 
vis may be folded into the acetabulum in front of the head, and an 



CONGENITAL DISLOCATIONS. 



41 



insecure reposition be made in this way. This happens in life and 
has been verified by operations and by dissections, after apparent 
reductions. 

The displacement of the head of the femur may be backward, 
upward, or forward; the backward or dorsal luxation is the most 
common. The inclination of the pelvis varies accordingly, for the 




9C 



A wo' 




Fig. 26. — Diagram of different angles of 
elevation of the femoral neek. 



Fig. 27. — Femur from congen- 
ital dislocation of- the hip show- 
ing small and deformed head 
and coxa vara. 



point of support is either above or behind the acetabulum, and the 
further back the more the pelvis tips and the more lordosis there is 
in the spine. 

Muscles alter in consequence of the changed relations, some 
shorten some lengthen; the gemelli, obturators and pyrimiformis 
are long, the adductors, hamstrings, and iliopsoas are short, the 



44 ORTHOPEDIC SURGERY. 

the parents to seek advice early. Usually when walking is well es- 
tablished at two, three, or even four years of age it is noted that the 
child's back is hollow, the buttock unduly prominent, that it wad- 
dles, or limps. Waddling is quite typical and the deep sudden dip 
as the weight falls on dislocated hip has been likened to "taking a 
step down stairs," only there is a sudden lunge or roll to the affected 
side as well as the quick dip downwards. There is no pain, or 
muscle-spasm. In older children and in most adults the promi- 
nence of the buttocks and trochanters with well-marked lordosis 
cause an attitude strongly characteristic of the affection. 

Physical Signs of Congenital Dislocation. — The chief sign of 
congenital dislocation is abnormal mobility of the hip and short- 
ening. Shortening is measured in two ways; by a comparison of 
the distance between the anterior superior spines of the ilium and 
the internal malleolus of each limb, and by noting the relation of 
the trochanter major to Nelaton's line. The former gives reliable 
data only in unilateral dislocations. Nelaton's line is drawn from 
the anterior superior spine of the ilium to the tuberosity of the 
ischium of same side; it should pass a trifle above the top of the 
trochanter in a normal hip, in congenital dislocation the trochanter 
is from a half inch to two inches above the line. 

Abnormal mobility of the hip is tested with the child lying flat 
on his back, by making tractions in the line of the leg with one hand, 
while the other resting on both the anterior part of the iliac crest and 
the trochanter feels the trochanter moving under the skin as it is drawn 
down; on letting up the pull it glides up again; on manipulating 
young children's hips are found unusually movable especially in 
rotation, and the thigh can often be twisted and the toes made to 
point more or less backward. 

In a double dislocation the perineum is broadened, generally 
the heads of the thigh bones are far back, the pelvis tipped well 
forward, the hollow of the back is much exaggerated, the abdomen 
protrudes, the whole pelvis appears widened, and the buttocks 
project far behind the shoulders and but little behind the line of 
the posterior surface of the thighs. 

Trendelenberg's Test. — A valuable physical sign of congenital 



CONGENITAL DISLOCATIONS. 



45 



dislocations is obtained by having the patient stand on one leg. The 
normal individual fixes his pelvis in balancing so that the buttocks 
are level with each other; standing on a dislocated hip the side of the 
raised foot falls, while in coxa vara the reverse takes place, it rises. 
It is of equal value in unilateral and bilateral luxations; both legs 
should be tried alternately. This is known as Trendelenberg's test. 





Fig. 30. 



Fig. 31 



Fig. 32. 



Fig. 30. — Lordosis in double dislocation. 

Fig. 31. — Trendelenberg's test, standing on luxated hip. 

Fig. 32. — A normal child standing on one leg, the buttocks are horizontal. 



Diagnosis. — The symptoms and signs are generally plain, the 
diagnosis offers usually no difficulty. There are many cases, how- 
ever, where it is impossible to make it at a glance; but the whole 
picture, the attitude, gait, measurements (especially from Nelaton's 
line), abnormal hip mobility, drawing down and sliding up of the 
trochanter, the lordosis, and in double cases the broad perineum, and 



4 6 



ORTHOPEDIC SURGERY. 



finally Trendelenberg's test of the line of the pelvis when the patient 
stands on one leg — all these carefully observed should leave no room 
for doubt. Other affections may be mistaken for it, however; 
among these are coxa vara, paralytic distortion from anterior pol- 
iomyelitis, separation of the upper epiphysis of the femur, patho- 
logical or traumatic, traumatic dislocation of the hip, even hip dis- 
ease and spinal caries; the latter on account of the lordosis only. 




Fig. 33. — Congenital dislocation of the left hip in a child of two with spina 
bifida occulta. Note the great width of the two last lumbar vertebrae and the 
smallness of the pelvis on the side of the dislocation. {Children's Hospital, 
Dr. A. W. George's X-ray.) 



Absence of pain and tenderness, and absolute freedom of motion, 
even an excess over the normal motion, rule out all but coxa vara 
and paralysis; in these the head should be in its socket, if it can 
be felt outside they are excluded. The head can be felt as a round 
resisting mass under the femoral artery where it begins at Poupart's 
ligament if it is in the socket, otherwise it is not there. Diagnosis 



CONGENITAL DISLOCATIONS. 47 

is confirmed by taking radiographic plates. Radiography should, 
however, also be used to furnish more precise knowledge of the 
femoral deformity than one can acquire by palpation. It is some- 
times easy to feel that the head is out of place but it is impossible 
to feel exactly where it has gone, and unless this be known the 
amount of torsion of the neck upon the shaft of the femur remains 
unknown, and this ignorance cause failure to reduce or may even 
leave the trochanter instead of the head against the acetabulum. 
To ascertain by radiography the torsion of the neck one may take 
a series of plates, each with the patella pointing a different way, 
which is noted at the time of exposure; in one the toes should point 
inward and upward forty-five degrees with the horizon, in another 
straight up, another upwards and outward forty-five degrees, in 
another in extreme outward rotation; the patient remains lying on 
his back and the X-ray tube vertically above the hip. Whichever 
one of the skiagraphs shows the longest neck shows it in the hori- 
zontal plane; and knowing the position of the foot recorded at the 
time of exposure, one can readily, by rotating the thigh, place the 
limb in a position with the neck in a frontal plane and then bring- 
ing the axis of the condyles horizontal, one can follow the direction 
of the neck and know whether torsion be forward or backward 
and estimate it approximately in degrees of a circle. 

TREATMENT. 

Palliative treatment aims at the palliation of an irreducible 
condition not at reduction. Unfortunately but little has been done 
for the palliation of the irreducible luxations. By gymnastic exer- 
cises the muscles may be strengthened and the attitude and gait 
greatly improved; they must be persevered in for years or for life, 
and really they do the most good. Mechanical appliances like 
the stiffened leather jacket and the corset may improve and correct 
lordosis and in that way improve the walking. They must fit 
tightly about the pelvis. Kirmisson uses the stiff leather jacket with 
prolongations around the thighs and a turn buckle between the 
thigh pieces to spread the legs. A steel back brace with a well- 



48 ORTHOPEDIC SURGERY. 

fitted low metal band around the trochanters has been used by 
Young. Various plaster-of-Paris jackets and pelvic supports have 
been tried, and tight belts. Tenotomy or open division of the ad- 
ductors has improved the cross-legged gait and Kirmisson used 
subtrochanteric osteotomy with advantage in adults. All the var- 
ious splints which are used for hip disease and infantile paralysis 
have been tried. In adults stiffness replaces the previous laxity 
and temporary benefit may come from forcible manipulating and 
stretching under ether to restore hip motion; this gain should be 
maintained by exercises. For the attacks of pain and cramps in 
the muscles rest in bed and massage are usually all that is required. 

Adults and adolescents with congenital dislocation of the hip have 
been considered doomed to lifelong deformity, but Baer, of Balti- 
more, has reduced a double one twenty-five years old by incision 
and excavating the acetabulum; he failed on the second hip two 
years later. A small number of individuals over the age of puberty 
have been successfully reduced by various methods, although the 
proportion of failures at that age has been very great. May one not 
expect in the future to see them classed with adult club-foot, as 
reducible? 

Reduction of the Dislocation. — Reduction of congenital disloca- 
tion of the hip has been done by stretching the contracted muscles 
and tissues and replacing the head of the femur in the acetabulum 
without the use of the knife; and it is also done by incision and dis- 
section; so there are the bloody and the bloodless methods of re- 
ducing the dislocation. 

Prior to 1887, with one exception, the deformity was reduced 
but seldom and then only after many months of traction by weights 
in bed. Provaz, of Lyons, in 1847 had reduced fifteen cases — 
the preliminary extension lasted six months, the whole treatment 
two years. 

Simple Manual Reduction. — The first bloodless reduction under 
ether was performed by one of the surgeons at the City Hospital in 
Boston, Abner Post, in 1885. The case relapsed later. An Italian 
surgeon, Pad, showed at the International Medical Congress in Rome, 
in 1887, several patients successfully reduced by his manipulations. 



CONGENITAL DISLOCATIONS. 49 

Lorenz, of Vienna, studied Paci's method and worked out a scheme 
for bloodless reduction which has been used extensively by many 
with varying success. 

Schede divised another method. He used traction and abduc- 
tion in a machine every other day and after several tractions re- 
duced the hip and held it straight in plaster. Bradford and R. 
W. Bartlett devised a machine for stretching the shortened mus- 
cles, reducing the dislocation by the Lorenz method. Recently 
Mueller, of Chicago, devised a better position in which to hold re- 
duced hips in plaster. 

To Hoffa, of Berlin, is due the credit for a cutting operation of 
real value; also a method of bloodless reduction. It was mod- 
ified and used extensively by Lorenz, who later discarded it almost 
entirely in favor of his bloodless reduction. Hoffa had previously 
been resecting the femoral head with poor result. A combination 
method, bloodless and bloody at one sitting has been used; and 
several different routes are employed to gain access to the joint. 

Experience with all methods has shown that unless the reductions 
are performed on children the proportion of failures is very great. 
Double congenital dislocations should be reduced before five, single 
before seven, by the purely manual method. The mechanical 
method and operation by incision offer a fair chance to children 
two years older. 

Lorenz Method. —The bloodless method of Lorenz requires full 
anaesthesia; the patient lies with the legs over the end of the table. 
The surgeon stretches by pulling and twisting the leg, the assistant 
holds the pelvis firm and fixes it in one position; at first by strong 
downward tractions the trochanter is brought down to Nelaton's 
line, this is followed by forced rotations inward and outward; it then 
is forcibly abducted to a position at right angles to the body and a 
little beyond both with a straight and a flexed knee, the surgeon's 
hand kneading and striking on the belly of the adductor longus aids 
materially in the stretching; when the adductors are stretched, 
that is when abduction can be carried twenty degrees beyond a 
right angle with the body, the limb is brought again into a straight 
position. The next step is to stretch the hamstrings so the foot is 
4 



5o 



ORTHOPEDIC SURGERY. 



raised, without bending the knee, until the front of the thigh meets 
the abdomen and the toes the face. Next the head is made to 
dilate the capsule; the thigh is flexed beyond a right angle and the 
surgeon presses down and forward on the knee, twisting and try- 
ing to stretch the anterior part of the capsule and to free it from 
adhesions, and striving to get it below and a trifle in front of the 
socket. Then, to stretch the anterior muscles, with the patient on 




Fig. 34. — Double congenital dislocation of hips. {Children' s Hospital, 
Dr. A. W. George, Radiographer.) 



his side or face, the hip is hyperextended both in the straight and in 
extremely abducted position, taking care that the assistant really 
holds the pelvis and does not allow lordosis to simulate stretching 
the ilio-psoas. The hip should now be ready for an attempt at re- 
duction. The surgeon grasps the knee with the hand (right hand 
for right leg), flexes the thigh to a right angle, rotates inward, 
flexes and abducts slowly, keeping his other hand with the palm 
pressing on the crest of the ilium the thumb pushing from behind 



CONGENITAL DISLOCATIONS. 5 1 

upon the trochanter, trying to guide and lift it over the rim as the hip 
reaches the overabducted position, using also a little twisting of the 
knee as the thumb lifts and presses the trochanter. A wedge of 
wood about three inches high padded on top with leather may be used 
to rest the trochanter on and do the lifting. Failure means insuffi- 
cient stretching and so one tries again after manipulating-some more. 

When it reduces there is generally a sound and a sudden jump 
as in reducing a traumatic luxation; absence or marked lessening 
of this phenomenon may mean a fold of interposed capsule or a 
misfit joint. It is well in this case to dislocate and to reduce several 
times. Often a little straightening of the leg will redislocate; the 
amount of motion permitted without slipping out is a sign of security 
and of ultimate success. Insufficient stretching may cause it; this 
is to be remedied by more stretching. It is not possible to retain 
the head in place when the axis of the limb parallels the body, but 
this may be done if the trochanter is held in with the hand. How 
is one to know if the head is really in place ? If in the acetabulum, 
it lies beneath the intersection of Poupart's ligament and the fem- 
oral artery; when present it can be made to roll under the finger 
by rotating, when absent one misses the fullness there. 

Application of Plaster Bandage. — The application of the plaster 
bandage is fraught with danger of relapse. A piece of stockinette, 
sewed up like drawers, is put on with a piece of bandage inside for a 
scratcher, the ends emerging at the top and bottom, that is at the 
ankle and axilla; over this a few layers of sheet cotton wadding with 
felt over the bony prominences of the pelvis to diffuse pressure; then 
a firm cotton bandage about the pelvis and upper thigh; then a solid 
plaster bandage tightly applied with the hip held in "hyperabduc- 
tion, hyperextension, and outward rotation." If the dislocation be 
double, the position is the so-called "frog position." The top of the 
plaster is cut low in front to allow sitting up; it extends high above 
the iliac crests on the sides and back; at the knee it is cut away 
in the popliteal space to allow flexion and extension, but covers 
the front and sides of that joint to prevent rotation. The writer has 
had radiographic negatives made through these plasters to show that 
the reduction has been maintained within the plaster. (Fig. 35.) 



52 ORTHOPEDIC SURGERY. 

The first plaster is worn two months or more, and replaced 
by another with a slight straightening but maintaining still the 
outward rotation for two or three months more, then another, a total 
of five or ten months in plaster. The first few days are spent abed 
on account of the painful swellings from ecchymoses and torn mus- 
cles and nerves. Then the child gets up, is provided with a boot 
and high sole and soon learns to get about on his feet, if unilateral; 




Fig. 35. — Congenital dislocation of hip reduced and in plaster bandage. 
{Children's Hospital, Dr. A. W. George, Radiographer.) 



double reductions learn to straddle a low bench and use their feet 
in hitching it along; later they learn to walk sideways like a crab, 
supporting themselves with a stick. Unilateral cases need a very 
high sole at first, often six inches; crutches are not used by Lorenz, 
as he wishes the weight-bearing to cause absorption of the fibrous 
fat in the joint and the slow adaptation of a head and socket often 
quite dissimilar in shape. 



CONGENITAL DISLOCATIONS. 53 

Mueller, of Chicago, calls attention to the extreme forward torsion 
of the neck on the shaft of the femur described by Schede and Lange 
and thinks that this factor is responsible for many relapses after 
reduction. His new position for the plaster bandage he calls a neu- 
tral position of right-angled abduction to the trunk, one where the 
patella is approximately in the frontal plane and the leg and foot 
as the patient lies in bed hang down over the side. This method 
has been tried at the Children's Hospital on all the reductions dur- 
ing the last nine months, and although it is too soon to speak of the 
results they promise well so far. 

Reduction by Machine. — Manipulative reduction by manual force 




Fig. 36. — Plaster bandage after reduction applied in Mueller's position. 

is tiresome and difficult, especially in older children, and more or less 
inaccurate; it produces more laceration of the tissues than is neces- 
sary and swelling and bruises give much pain during the first 
few days. A machine for stretching the contracted tissues in con- 
genital dislocation was devised by Mr. R. W. Bartlett, of Boston, 
and described by him in 1903. The one here described is in use 
at the Children's Hospital; it was devised by Bradford who had 
previously used Bartlett's machine on some forty reductions. 

Two steel plates, one-eighth of an inch thick, measuring ten by 
twelve inches, are fixed over each other with a half-inch space between 



54 ORTHOPEDIC SURGERY. 

and so arranged that one of the ten inch sides can be attached to 
the edge of a table by a vertical front plate which is bent so as to 
grasp the under side of the table top. This rests flat on the table; it 
is perforated with half-inch holes every two inches to hold cylin- 
drical steel rods or pegs about nine inches long. The vertical front 
plate is also perforated. A long steel traction arm with windlass 
or screw-and-spreader, five pegs, two metal sleeves, a short straight 
lever, and two collars bearing each a flat arm to hold the pelvis, 
complete the apparatus. 

The child lies on its back with a soft pad under the sacrum 
and the perineum against two sleeve-covered pegs placed in the 
centre holes of the horizontal plate. Traction is usually applied 
with a long thong of raw-hide wound about the ankle previously 
protected with felt and leather padding. One end of the traction 
arm rests in a hollow or vertical plate beneath the hip, the assist- 
ant secures the thong to the windlass and winds it to make power- 
ful traction, the pelvis having been secured against slipping by a 
peg on each side of the ilium bearing the collars and short arms 
which rest upon the anterior spines and symphysis pubis. During 
traction the limb is rotated alternately inward and outward with 
force, and the traction rod and limb are slowly forcibly abducted. 
After reaching a position a few degrees beyond a right angle to 
the body axis with the limb horizontal the leg is straightened and 
the abduction repeated with the foot on a plane considerably lower 
than the hip. By placing the end of the short lever in the hole next 
to the perineal peg, and lifting, pressure is directed on the tro- 
chanter, the head is forced well forward to stretch the capsule, 
and at times reduction may take place. Nevertheless the ham- 
strings are to be stretched as in the Lorenz method, unshipping the 
traction arm. The reduction is then possible if there has been 
enough stretching and it may be done with the hand, or the short 
lever may be used to pry the trochanter up over the rim. Inse- 
curity is again either a sign of incomplete stretching, of infolded 
capsule, or of an acetabulum unsuited to hold the femoral head. 
More manipulating will remedy the first condition, not the others; 
if, therefore, it fails to give a more stable hip, the surgeon may either 



CONGENITAL DISLOCATIONS. 55 

apply a plaster bandage in the position of greatest security and wait, 
or he may at once proceed to the bloody method of reduction by in- 
cision, and in some cases this combined method is rational. 

That position of the hip which resists most strongly all attempts 
at dislocation appears to be the rational one to use for the first re- 
tention bandage. It is frequently one of marked abduction and 
inward rotation; it is here that a knowledge of the way in which 
the neck of the femur sets on the shaft should aid the surgeon, a 
knowledge gained by previous radiographs as described on page 47. 

Tenotomies. — Where failure to obtain a stable reduction arises 
from insufficient stretching, tenotomies and open division of the re- 
sisting fasciae and muscles are first in order. The fascia lata, the 
abductors, the hamstrings, and the ilio-psoas may each be too short. 
The tendon of the adductor magnus exerts a strong force to oppose 
drawing the femur down. A small incision a finger's breadth above 
the upper border of the tubercle on the internal condyle of the femur 
exposes the tendon under the fascia lata where it is readily isolated, 
lifted on the director, and cut. Open division is preferable for the 
hamstrings and ilio-psoas tendons also. 

Bloody Reductions, or Reductions by Free Incision and Dis- 
section. — Hoffa originally used the posterior incision Langenbeck 
employed for excision of the hip dividing from their attachments all 
the muscles inserted in the trochanter major. 

Today the operator aims to lay open the capsule by the shortest 
route which gives a clear view of its interior, to replace the head 
in its socket and to stitch the capsule so as to retain it in place, 
doing as little cutting as possible to the muscles, but stretching 
them as thoroughly as possible before beginning the cutting method. 
The machine stretching is a handy adjuvant. 

Bradford's incision is made along the anterior border of the tensor 
vaginae femoris muscle and between it and the front border of the 
gluteus medius leading by a short dissection to the tendinous origin 
of the rectus femoris at the anterior inferior spine; leaving these on the 
outer side one comes immediately upon the capsule; strong retraction 
will give ample room if the skin incision be large enough, or a short 
cross incision can be added to give more space. By flexing and ro- 



, 



56 ORTHOPEDIC SURGERY. 

tating the thigh the capsule may be cut in two, leaving a short cuff 
on the femoral neck and a long one on the pelvis; the femoral neck is 
rotated outward and forward, and retracted so as to turn the head and 
neck out of the way and allow unobstructed examination of the inte- 
rior of the pelvic part of the capsule; this may be facilitated by re- 
tracting the edge of the cuff with a couple of silk sutures in its upper 
and lower anterior border. The ilio-psoas may need to be drawn 
aside and rarely it may have to be cut before a good view of the in- 
terior of the capsule can be had. A small channel is looked for 
at the apparent bottom leading inward, forward and downward 
around a corner into the real acetabulum; the finger, though often 
too large to penetrate, will detect a sharp edge or hymen of 
capsule which is easily divided with a small scalpel, then the 
finger penetrates and explores by touch so as to ascertain what the 
acetabulum is like and whether the head is liable to stay in it, and 
incidentally if the capsule has been divided sufficiently to let the 
head pass. In order to avoid risk of folding the capsule into the 
cavity in front of the head a small retractor or a little Sim's specu- 
lum is put into the acetabulum along the upper part of the cuff of 
capsule and serves like a shoe-horn to guide the femoral head as 
one manipulates it carefully down into the socket. 

Next, one tests the readiness to redislocate in different positions 
of the thigh; sometimes the Y ligament of Bigelow prevents bring- 
ing the limb down from flexion; by a little care it can be exposed, 
divided by a Z-shaped cut as in lengthening tendons. It is a good 
plan to place a stout double-silk suture through the toughest part 
of the capsule at the lower border of its pelvic attachment, a double 
suture, tying one suture around the neck and the other around the 
shaft at the base of the great trochanter, both passing close to the 
bone. The pelvic cuff of capsule is too large, it may be cut in the 
line of the neck to permit overlapping or it may be "gathered" and 
stitched to itself and to the edge of the femoral part. A small gutta 
percha wick may be left in the joint emerging from the low angle of 
the incision to be slipped out at the first dressing if there be no in- 
fection; the skin and fascia are sutured separately. A small dress- 
ing of sterilized gauze is applied so as to be readily changed as a 



CONGENITAL DISLOCATIONS. 57 

window dressing subsequently. Plaster bandages are then put on 
as one would after a bloodless reduction. The position for reten- 
tion must be one whose stability has been tested; it should also 
place the axis of the neck in a nearly horizontal plane in both stand- 
ing or lying attitude. It is not often necessary to use abduction 
beyond ninety degrees. 

When there is great disparity between the form of the head and 
socket one may pare down the head or one may scoop out the 
socket, bearing in mind that if articular cartilage be taken from 
both sides of the joint there is more chance of ankylosis. 

The strictest asepsis is to be maintained in operating and dressing; 
the dissection is greatly simplified if all bleeding points are imme- 
diately stopped by forceps-pressure or twisting, leaving a clean dry 
wound and avoiding blunt dissection. Proof of reduction should 
be sought by a radiographic plate after operation, taken through the 
plaster bandage. 

If the deep retaining sutures have been firmly placed and tightly 
tied the danger of redislocation is little and early walking on crutches 
is encouraged; early weight-bearing must depend upon the amount of 
resistance to dislocating at time it was reduced; early walking un- 
doubtedly favors recovery with motion, but it may add to the risk 
of redislocation. . 

Plaster-of-Paris bandage after reduction by incision, usually 
need not be continued more than three months, one month with- 
out weight-bearing on crutches, one month using the foot a little 
in the original plaster, and the third month in a straightened posi- 
tion in plaster gradually increasing the amount of weight-bearing; 
that is if the solidity of the joint is good at the close of the opera- 
tion. When plaster is discarded exercise should be much restricted 
at first, gradually increasing from day to day both the amount of 
weight borne on the limb and the amount of motion at the hip. 
There should be a prescribed set of daily exercises designed to re- 
store mobility and strength lost by prolonged immobilization. 

Anterior Transposition of the Hip. — Lorenz has designated, 
under the term anterior transposition of the hip, changing a posterior 
into an anterior dislocation. It has been found of great service in 



58 ORTHOPEDIC SURGERY. 

many cases because tipping of the pelvis and lordosis disappear if 
the body-weight be slung above instead of behind the acetabulum ; 
shortening of course remains. It is of great use for relapsed cases 
and for those above the age limit. If consent to a cutting operation 
has not been given and the surgeon finds an unstable joint, he should 
place the hip in the anterior position. The usual manipulations for 
stretching and reducing having been previously performed, the thigh 
is grasped, flexed, rotated, and abducted so as to push the head into 
the space just above the socket, pressing strongly inward and rotat- 
ing the thigh. If the head can be wedged under the long head of the 
rectus femoris muscle it is more liable to stay there permanently; 
a less good resting place is below the anterior spine under the 
sartorius and tensor vagina? femoris. Sometimes this position of 
anterior transposition will slowly come of itself after what appeared 
to be a perfect anatomical reduction and in these cases the end re- 
sult may be good, but not always is the ending so favorable. It 
depends on obtaining a secure and lasting anchorage on the ilium 
and failure to obtain this means a return to the dorsal dislocation 
with its deformity and disabling gait. 

Summary. — In summing up the different forms of treatment one 
is struck with the progressive improvements which have come forward 
in a short space of time. It is too early to know comparative merits, 
end results are still disappointing in many cases, yet in it all there 
is the bright promise of future success, and the discouraging fail- 
ures of today will undoubtedly teach one to do better. Has not 
the same process of evolution been seen in the treatment of club- 
foot? Nobody today regards club-foot as incurable at any age, 
yet how often since the days of Scarpa has the promise been made 
that the latest method would cure every club-foot? Are there not 
today a number of methods in use more or less indispensable if one 
would have all club-feet cured ? 

A safe routine to follow in the choice of operative methods would 
be the following: Do not operate to reduce congenital dislocation 
until the age of diapers is passed on account of the plaster bandages; 
children under five years of age have the best chance of a success- 
ful bloodless reduction by manipulation only; older ones by the 



^ 



CONGENITAL DISLOCATIONS. 59 

machine reduction. All cases which have relapsed, unless a safe 
anterior transposition exists, and all cases which at the time of re- 
duction fail to show a satisfactory resistance to redislocation should 
undergo the cutting operation after a thorough stretching. Fail- 
ure after manipulation may sometimes be converted into success by 
dividing some resisting structure like the tendon of the adductor 
magnus, the front of the fascia lata or the hamstrings which had 
failed to yield to manual or mechanical force. Excavation of the 
acetabulum and trimming the femoral head are only needed to correct 
considerable disparity in the form or size of head and socket. Deep- 
ening the acetabulum was used by Baer in his successful adult 
case, and is extensively used by many operators like HofTa; its only 
drawback is the chance of ankylosis. 



A 



CHAPTER V. 

CONGENITAL LUXATIONS CONCLUDED ; SUBLUXATIONS 
OF HIP, KNEE, AND OTHER JOINTS. 

CONGENITAL SUBLUXATION OF THE HIP. 

Congenital subluxations of two kinds have been described. In 
one there is a displacement of the joint upward which may be dem- 
onstrated by the X-ray showing a difference in the level of the 
two hips with shortening usually of less than an inch and a slight 
limp. They resemble coxa vara only the angle of the neck of the 
femur is normal, the whole joint too high, as if the acetabulum had 
migrated upward from cause unknown. In the other, an infant or 
child has the power of voluntarily displacing the femoral head up 
onto the rim of the socket and reducing it with a snap; it is called 
snapping-hip. It occurs on semi-flexing the thigh and adducting 
it, and is particularly apt to be done by a baby in a fit of temper. 
I have seen it recently in a girl of eleven who could do it at will on 
either hip when standing in her natural attitude. Immobilizing 
as much as one can in a plaster-of-Paris spica has been tried with 
varying success; as it gives no trouble, it is usually disregarded and 
supposedly outgrown. 

CONGENITAL DISLOCATION OF THE KNEE. 

Congenital dislocation of the knee is not very rare; it is hered- 
itary and three in a family have had it; it is usually a displacement 
forward of the tibia on the femoral condyles; it is called genu 
recurvatum, when the tibia makes an angle approaching a right 
angle with the femur; but it is a very common thing for young and 
old to exhibit knees which bend somewhat back, and it is not rare 
to find them bending forty-five degrees in this direction. A right 

60 



CONGENITAL LUXATIONS. 6 1 

angled deformity shows the prominence of the knee directed back- 
ward so that the condyles of the femur can be plainly seen and felt, 
lateral motion is often present to a slight amount ; there is general laxity 
of joint and the patella may be small or absent. Alterations in the form 
of the bones, cartilages, and ligaments have been described and ankylo- 
sis may occur rarely. In babies treatment aims to permit normal 
motion in the joint, and to prevent the use of the limb in abnormal 
positions, trusting that nature will gradually shorten the ligaments 
and muscles which limit normal motion. Children who walk 
should wear a light double upright knee and ankle jointed appara- 
tus designed to prevent all lateral motion and prevent hyperexten- 
sion of the knee, allowing it perfect freedom to extend and flex 
almost to the normal limit. Gymnastic exercises are given to 
strengthen and develop the hamstring muscles; their use diminishes 
the time of splint wearing. Bacilieri points out the ease of correc- 
tion in the first days of life; he considers hyperextension is not the 
result of the quadriceps' pull but comes from the faulty action of the 
biceps, the insertion being too far forward, so that it extends instead 
of flexing the knee. 

CONGENITAL SUBLUXATION OF THE KNEE. 

Three forms are found in the knee-joint — congenital backward 
subluxation, lateral dislocation, and dislocation of the patella. The 
first is very rare; for its treatment the reader is referred to p. 8. 

Lateral dislocation, or snapping knee, is uncommon. Two cases 
were described by the writer in 1898. Both were in the neighbor- 
hood of a year old and could voluntarily snap the knee out in the 
semi-flexed position; it did not hinder walking, there was free lateral 
tilting and sliding of the knee, and in position of semi-flexion there 
would sometimes come a sudden snap when the inner femoral 
condyle became very prom'nent the shin was no longer in line with 
the thigh; on palpation one felt that the internal condyle of the tibial 
head was against the external femoral condyle. The dislocation 
occurs because all the ligaments of the knee are too long to resist 
the outward pull of the popliteus muscle in a flexed knee. 



62 ORTHOPEDIC SURGERY. 

Treatment.- — Treatment is directed to the prevention of abnormal 
movements by the appliance described on page 61. 

Congenital dislocation of the patella has often been described 
and some regard all cases of habitual slipping patella as of antena- 
tal origin; the writer believes some cases to be due to congenital 
misinsertion of the ligamentum patellae; but most come from knock- 
knee with an unnaturally long patellar ligament. It is primarily 
due to lax ligaments, weakness of the vasti, and too long a liga- 
mentum patellae. Three forms are described, outward, inward, 
and upward displacements; the only common one is the outward dis- 
placement with knock-knee; a very long patella tendon produces 
the upward form. The amount of impairment of extension de- 
depends on the insertion of the patellar ligament. If it be into 
the tubercle of the tibia all is well, if off on one side of it, it will 
slip and become misplaced, and if its insertion be into capsule and 
fascia it will utterly fail to extend the leg. Treatment should aim 
to restore lost function and to prevent habitual dislocation. There 
is no fixed rule. The surgeon has to study the amount of disability 
and the exact anatomical condition which confronts him. Palliative 
measures, elastic knee-caps and the jointed splint with springs 
pressing on the sides of the knee pan are often of use. If they fail 
the form of operation must vary to suit the condition. 

(it Idthwait has operated by changing the insertion of the patellar 
tendon inward so as to bring the line of pull straight. Most patellae 
dislocate outward and occur in girls with long patellar tendons. A 
vertical incision is made from the tibial tubercle upward through 
which the whole patellar tendon is exposed and split in two ver- 
tically; the outer half separated from the tibia is passed under the 
inner portion and firmly sutured under the periosteum. This gives 
a straight line of pull. 

Congenital Dislocation of the Ankle. — It has been described 
under absence of the tibia and of the fibula, pages 8 and 9. 

CONGENITAL DISLOCATION OF THE SHOULDER. 

They are not rare if one includes those due to obstetric paral- 
ysis; congenital non-paralytic dislocations are decidedly uncommon. 



CONGENITAL LUXATIONS. 63 

That it exists cannot be doubted. Autopsies of a fetus of eight 
months and of a child of three days have been described in detail 
where no glenoid cavity was found. Many of the dislocations 
reported as congenital are due to obstetrical paralysis, that is paral- 
ysis produced by rupture or crush of a part of the brachial plexus 
at birth. This form of paralysis will be considered on page 78. 

Pure congenital dislocations may be subspinous, subcoracoid or 
subacromial, and are rare in little children without paralysis. Whit- 
man has obtained a reduction by manipulations under ether, stretch- 
ing the tissues as in the bloodless reduction of congenital dislocation 
of the hip. After reduction the arm was fixed in plaster for months 
in the attitude of extension on the scapula to force the head of the 
humerus forward and in outward rotation to overcome the tendency 
to rotate inward. A long period of exercises followed this period 
of fixation. Phelps, of New York, described an operation for sub- 
spinous luxation, which he had used on three patients. A posterior 
incision along the margin of the deltoid opened the joint; on account 
of the small size of the imperfect glenoid cavity part of the head 
of the humerus had to be cut away and the redundant pos- 
terior portion of the capsule was excised; after reduction the pos- 
terior part of the capsule was tightened up by sutures to prevent 
the head falling backward into the old position, and the arm was fixed 
in plasier-of Paris bandage; the immediate result was good. 

CONGENITAL DISLOCATION OF THE ELBOW. 

But few cases are known and different conditions described. Both 
bones of forearm may be displaced forward or backward, a back- 
ward displacement of the radius with a subluxation of the ulna and 
absence of the external condyle, and a dislocation of the radial head 
alone have all been noted in literature. At times there is no dis- 
ability, at other times the head of the radius or the entire elbow 
have to be resected. 

Blodgett, of Detroit, analyzed fifty-one cases of congenital luxa- 
tion of the head of the radius. It is about twice as common in the 
male and as often double as single ; forty-six percent were dislocated 



64 ORTHOPEDIC SURGERY. 

backward, forty forward, twelve outward, and two percent inward. 
In a third of them there was a bony fusion of the upper ends of the 
bones of the forearm. A condition similar to congenital disloca- 
tion has been attributed to syphilis by Cotton and Bottomley and 
Ambard. Congenital dislocation of the elbow is hereditary, seven 
cases are reported in four generations of one family by Abbott. 

The condition should be studied with radiographs; they are a 
great aid to more precise anatomical diagnosis, together with care- 
ful palpation. Burrell recently divided the line between upper 
fused ends of the radius and ulna in such a case, but they grew 
together again. 

CONGENITAL DISLOCATION OF THE WRIST. 

The condition has been considered under club-hand, p. 4. It is 
rare without a defect of the radius or ulna. 

Subluxation of the wrist, the wrist and hand being in front of the 
line of the forearm, has been attributed to congenital laxity of the 
joint from long ligaments, also to rickets years before. Little evi- 
dence of its congenital origin exists. Replacing and holding the 
hand in extension for many months in a splint or leather appliance 
with massage and graded exercises has been the treatment. 



CHAPTER VI. 

DISEASES CAUSING DEFORMITY WHICH ORIGINATE 
BEFORE BIRTH. 

FETAL SYPHILIS. 

Fetal syphilis is known to exist and frequently leads to the death 
of the fetus. This affection in and about the joints of the new-born 
has been described by Parrot as an osteochondritis, characterized 
by irregular enlargements of the epiphyses of the long bones which 
seem to encroach upon the shaft and enclose it, as it were, in a cup. 
Marfan recently called attention to the frequency of suppurative 
disease of such joints in the early weeks of life, resulting quite often 
in ankylosis. The periosteum is thickened and the shaft considerably 
enlarged. (See Chapter XL) Separation of the epiphyses is said 
to be common and may cause a pseudo-paralysis. Further con- 
sideration of bone syphilis will be found on page 203. 

CONGENITAL TUBERCULOSIS. 

Congenital tuberculosis occurs in cattle, sheep, horses, and pos- 
sibly in man. Human infants in the early weeks of life are occa- 
sionally observed with a cold abscess about the hip or knee, which 
in older children would take a month or more to form. The writer 
has drained several of these and in each instance no organisms 
were found in the pus. Whether they were tuberculous or whether 
the joint disease from which they started was tuberculous, it was 
impossible to say. 

FETAL RICKETS. 

The existence of congenital rickets has been a matter of dispute for 
many years. The trend of opinion today is against it. Syphilis, 

5 65 



66 



ORTHOPEDIC SURGERY 



chondrodystrophia fetalis, and osteogenesis imperfecta can 
made to explain what was formerly called fetal rickets. 

ACHONDROPLASIA. 



be 



Chondrodystrophia fetalis or achondroplasia is an affection some- 
what like cretinism and rickets. It dwarfs the individual by pre- 
venting the growth of the arms and legs 
while the trunk continues to grow. The 
infants at birth are said to show signs 
of severe rickets with short arms and 
legs, a large head, depression of the root 
of the nose, beading of the ribs, flatten- 
ing of the sides of the chest, and enlarge- 
ments at the wrists and ankles. The 
affection, however, is pathologically dis- 
tinct from rickets. It begins between 
the third and fifth month of intrauterine 
life; as growth goes on, the short arms 
and legs are in strong contrast with the 
length of the trunk. Mild cases grow 
to adult life as bow-legged dwarfs, but 
many are still-born or live a few weeks. 

Miiller, in i860, showed that it differed 
from rickets and cretinism in having very 
little proliferation of the cartilages of the 
epiphyses. Of course if the epiphyseal 
cartilage does not proliferate a long bone 
cannot lengthen. 




Fig. 37. — Chondrodystro- 
phia fetalis. {Children's 
Hospital.) 



OSTEOGENESIS IMPERFECTA. 

Osteogenesis imperfecta, congenital brittle bone. This affec- 
tion is a general one of all the bones of the body and is character- 
ized by multiple fractures occurring before, during and after birth 
in infants otherwise healthy and well formed. The fractures 
are often painless and are often produced spontaneously by the 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 67 




action of the infant's muscles. The nature of the affection is 
unknown. These infants sel- 
dom live over a year. It is, 
fortunately, uncommon. 

Brittle bones are hereditary 
in 15 percent of the cases, in 
some instances involving an 
entire family, an instance of 
which is described by Willard, 
of Philadelphia; among 7 
daughters, 6 sustained from 
one to four fractures, and of 3 
sons, all had suffered from one 
to four early fractures, while 
one grandchild had two frac- 
tures in four weeks. In some 
families, it appears among 
brothers and sisters where the 
tendency in the family has not 
been shown previously; and 
once the affection was reported 
in 2 cousins. Those born with 
one or two intrauterine frac- 
tures are likely to live for a 
while but most babies who 
come into the world with 
many fractures are dead born. 
Intrauterine fractures are usu- 
ally accompanied by fresh 
fractures produced during 
birth; these usually unite 
quickly, but in some, union 
takes place slowly and a few 
do not unite; the callus is often 
small, and crepitus is slight, 
they are painless. The thighs are most often broken, followed by 




Fig. 3cS. — Chondrodystrophia fetalis, 
short bones the shaft wide where it joins 
the epiphysis which is small. (R. W. 
George, Radiographer.) 



68 ORTHOPEDIC SURGERY. 

the legs, and the long bones of the upper extremity; but the clavicles, 
ribs, and the lower jaw, may be broken. Other congenital deformities 
seldom accompany the condition, but hydrocephalus and club-foot 
have been observed. The deformities produced by the disease may 
be due to fractures united with improper alignment, or a bending 
of the bones may be present due to the disease itself independent 
of fracture, a bending analogous to rickets, osteomalacia, and 
achondroplasia. Forward bending of the tibia, forward and out- 
ward bending of the femur, outward bending of the humerus, and 
distortion of the pelvis have been reported; scoliosis has been ob- 
served. 

The children are usually smaller than the average at birth and 
the extremities are sometimes abnormally short in proportion to 
the trunk. The skin is normal or thin, not thick and edematous; 
the cretinoid type of face has rarely been alluded to; but the cranium 
is imperfectly ossified; and all bones cast a feeble X-ray shadow 
and are thin and atrophic, for the medullary cavity seems to be 
increased at the expense of the cortex. The epiphyseal lines are sharp 
but are less regular than normal; both fractures and infractions 
may be shown by the X-ray. Microscopic section of the spongy bone 
shows the trabecule with imperfect bony lamination and imper- 
fect bone corpuscles which are oval, not stellate, and there are no 
canalicular between the lacunae; on the surface of the trabecular 
are some osteoblasts and the bone marrow is apparently normal. 
At -the epiphyseal line, the zone of proliferation is almost absent 
and the zone of hypertrophy very little developed, although the 
cartilage cells are arranged in regular columns separated by strands 
of hyaline matrix; the line of provisional calcification cannot be 
made out. The primary trabecular are composed largely of per- 
sistent cartilage cells in a matrix containing a few granules of lime; 
they are beset by too few osteoblasts but farther from the epiph- 
ysis osteoblasts are present almost as in normal bone; the marrow 
near the epiphysis may be edematous or myxomatous. 

Brittle bones is a general term used to describe any condition 
when people's bones break with little provocation. Osteogenesis 
imperfecta is not the only affection in which brittleness of the bones 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 69 

has been observed; early fractures occur also in chondodystrophia 
fetalis, in syphilitic bone disease, and in some early cases of rickets; 
it occurs also in osteomalacia of childhood; in senile atrophy or 
osteoporosis, in inflammatory diseases, as osteomyelitis, tuberculosis 
neural arthropathy of tabes, syringomyelia, in paralysis, in malig- 
nant turners of the bones, and in bone cysts. Brittle bones without 
known cause also occur in little children who later outgrow the 
condition. 

No satisfactory treatment of osteogenesis imperfecta has been 
formulated. In a recent fatal case reported by Lovett and Nichols, 
the child was kept upon a pillow, not handled or allowed to sit up, 
and the clothing arranged so as to disturb him as little as possible 
in changing it; but in spite of every precaution, ten partial or com- 
plete fractures occurred before he was five months old. 

DEFORMITIES DUE TO DISEASES OF THE NERVOUS 
SYSTEM OF FETAL OR INTERPARTAL ORIGIN. 

SPINA BIFIDA. 

Paralytic Distortions from Spina Bifida. — Many spina* bifida 1 
have club-feet, club-hands, distortions of the hi}) or knee, hernia, 
in fact, all sorts of malformations. Usually one finds a paralysis 
of the leg with the club-foot, and sometimes a loss of sensation and 
trophic changes in the skin; even trophic ulcers of the skin have been 
observed. The same sort of paralysis and deformity accompanies 
spina bifida occulta, and its origin may pass unnoticed until some 
day the back is examined and the peculiar local growth of hair 
is found. 

Of the club-feet associated with spina bifida, some are true con- 
genital club-feet, many are due to paralysis. Unfortunately, oper- 
ating on the sac has seldom benefited the paralysis. Treatment, 
therefore, aims to restore the function of the foot either by the use 
of a mechanical apparatus, or by a conservative operation, like 
a tendon transference. The apparatus must vary with the individ- 
ual case, and must be very light for the limb is weak. The club- 



70 ORTHOPEDIC SURGERY. 

foot shoe for equino-varus, or the sole plate for valgus, or the short 
caliper splint with a stop for simple toe drop, all these may be of 
service (see Chapter XXI). Exercises, manipulation and massage 
should be persevered in. 

The indications for these conservative operations are the same 
as for long standing infantile paralysis, but one must heed the pres- 
ence of extensive trophic disturbances. Tendon transplantation, 





Fig. 39. — Spina bifida two months after operation, hydrocephalus and club- 
foot. {Infant's Hospital.) 

tendon shortening, and arthrodesis of the ankle-joint may be 
advisable. 

Kirmisson reports a successful Pirogoff's amputation done on a 
young man with equino-valgus to get rid of constantly recurring 
trophic ulcers. 

For a description of operations for paralytic club-foot see Chap- 
ter XIX. 

HEREDITARY ATAXIA OR FRIEDREICH'S DISEASE. 

According to Dejerine and Letulle, this affection is produced by 
a gliomatous growth originating in an imperfectly developed cen- 
tral canal of the cord. It is therefore considered as a disease of 
fetal origin. 

It is an affection of childhood, resembling in many respects loco- 
motor ataxia, and oftenest occurs among brothers and sisters but it 
may be inherited. Both sexes are attacked. 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 7 I 

In the cord there is a sclerosis of the posterior columns, degenera- 
tion of the lateral columns, and the central canal of the cord is al- 
tered into an irregular mass or masses of various shaped cells string- 
ing out into the surrounding gray matter with degeneration of the 
columns of Goll and Burdach, and degeneration of the posterior 
roots. It is a neuroglious sclerosis, "A gliosis of the posterior 
columns due to developmental error." 

Clinically, the child has an ataxic gait without the lightning pains 
and crises of locomotor ataxia and without the Argyll- Robertson 
pupil. The knee jerk disappears, incoordinate movements begin in 
the legs, spread to the arms, neck, and head; lateral curvature of 
the spine, talipes valgus and flexion of the knees are common ac- 
companiments. 

Robbins, of Washington, D.C., recently summarized a hundred 
cases from medical literature, of whom 47 had deformed feet, and 48 
lateral curvature of the spine, usually the right dorsal convex; speech 
was affected in 70. 

The affection though progressive, may last as long as 30 years 
and is incurable. Symptomatic treatment for the lateral curvature 
of the spine and distortions of the limbs should be employed. 

PROGRESSIVE MUSCULAR ATROPHIES. 

Progressive Muscular Atrophies, the Dystrophies. — This group 
of affections in childhood is inherited, and is, therefore, included 
here. In the adult other causes for it are found. 

The Aran-Duchenne type is comparatively common in adults 
over 25 years old associated with atrophy of the anterior horns of 
the gray matter of the cord; but very few children have been known 
to have it. Hoffmann reports a brother and sister in whom the dis- 
ease began at 4 years of age. 

The symptoms are ill-defined pains with loss of power and 
atrophy of the hand. Both the thenar and hyptohenar emi- 
nences of the palm of the hand become atrophied and sunken; 
the interossei and lumbricales shrivel, leaving depressions between 
the metacarpals; then the wasting spreads to the flexors and ex- 



72 ORTHOPEDIC SURGERY. 

tensors of the forearm, a contraction sets in, claw-hand developes, 
and the deltoid atrophies. Then the remaining muscles of the upper 
extremity, those of the trunk, and of the lower limb atrophy. This 
order is not always adhered to, but is unusual for the legs to atrophy 
early soon after the process commences in the hand. Sensation is 
not disturbed. The disease progresses slowly and is incurable. 

The peroneal or leg type is hereditary or a family affection, be- 
ginning in very early life or not later than 20 years. It is asso- 
ciated with degenerative changes in those peripheral nerves which 
supply motion to the feet and hands. But the spinal cord shows no 
lesions. In the muscles the transverse striations are diminished 
and the nuclei increased. The peroneal muscles and the intrinsic 
muscles of the feet first develop atrophy and weakness; either 
talipes equinus or equino-varus is produced by the contraction of tin- 
antagonized muscles. In time the whole leg atrophies, but the upper 
extremity and body are affected late in the disease. Fibrillary con- 
tractions of the muscles are visible, electrical reactions are diminished 
or absent, the knee jerk is absent; sensation may be slightly 
impaired, and hyperesthesia has been noted. The disease progresses 
very slowly. There are often long periods without change, but it is 
incurable. 

By correcting the club-foot, locomotion may be maintained, 
which adds to the general health of the patient. This may be 
accomplished by mechanical or surgical means. (See Chapter 
XIX.) Massage and electricity prevent stiffness and seem to retard 
the progress of atrophy. 

The progressive muscular atrophy of the Aran-Duchenne type 
is associated, as we have seen, with lesions of the cord, the peroneal 
type with degenerative changes of the motor nerves supplying the 
hands and feet without cord lesions. 

The following atrophies or dystrophies of the muscles, though 
they closely resemble the preceding in many respects, are without 
discoverable lesion of the brain, cord, or nerves. They fall into 
three types: The juvenile muscular atrophy of Erb, face and shoul- 
der atrophy of Landouzy and pseudo-muscular hypertrophy. 

They are hereditary or are seen among brothers and sisters. 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 73 

Although in pseudo-muscular hypertrophy the limb shows increased 
size instead of a diminution, the muscle itself microscopically shows 
atrophy, for between the bundles of muscle fibres, the fibrous 
tissue is greatly increased and infiltrated with fat. The electric 
reactions of such muscles are diminished, but the reaction of de- 
generation is never present. 

Erb's Juvenile Atrophy. — This is a disease of late childhood and 
youth, attacking girls usually. The angel-wing deformity from paral- 
ysis of the serratus magnus is common early in the disease, but the pec- 
torals, trapezius, rhomboid, latissimus dorsi, and triceps become weak 
and atrophy; then muscles weaken and atrophy in the lower back 
and thigh, but the leg below the knee is one of the last places in- 
volved. Talipes arising from unbalanced muscle-antagonism is 
of the equino-varus or equino-valgus type. There is weakness 
but no true paralysis of the muscles. The calf muscles are the 
very last to be affected and the forearm and hand escape. Weak- 
ness with an enlargement instead of atrophy has been seen occa- 
sionally in the deltoid and the muscles about the scapula. The 
progress of the disease is very slow — it has lasted 40 years. Symp- 
toms of bulbar paralysis seldom occur but atrophy and weakness of the 
muscles of respiration, especially the diaphragm, have caused death. 

Like the other forms, it is incurable; mechanical appliances and 
tendon transferences may be used for the correction of club-feet 
and other distortions. 

Landouzy-Dejsrins or Face and Shoulder Type of Muscular 
Dystrophy. — This type of muscular atrophy differs only in that 
the face is first involved. The expression is dull and flaccid, the 
lips puffy, and later, the shoulders, arms, back, and legs undergo the 
same changes as in the preceding form. 

Westphal describes a case of typical pseudo-muscular hyper- 
trophy in which the muscles of the face were involved early just 
like this Landouzy-Dejerine form. The ocular muscles and mus- 
cles of mastication are never affected. 

Pseudo-Muse alar Hypertrophy. — Pseudo-muscular hypertrophy 
is by no means an uncommon frequenter of orthopedic clinics. 
Hoys usually from 5 to to years of age are attacked by it; 



74 



OETHOPEDIC SURGERY. 



it is steadily progressive and incurable. It may be recognized 
at a glance by the association of a magnificent development of the 
calf of the leg combined with so much weakness that the boy 
cannot rise without climbing up on himself as in Fig. 40. It 
has been known to begin in infancy; in that case, the boy 
learned to walk late and helped himself along by leaning on 

chairs, etc. There is no disturbance 
of sensation or of the function of the 
bladder and rectum. The weakness 
begins in the legs, extends later to the 
back, shoulders and arms; muscular 
antagonism may become unbalanced 
through unequal distribution of weak- 
ness, producing flexion at the hips and 
knees, talipes equinus, round shoulders, 
and lateral curvature of the spine. 
The gait indicates weakness, a shuf- 
fling gait; there is difficulty in walking 
up stairs, falls are frequent. Some- 
times the gait is rolling, as the boy 
throws his body-weight alternately on 
each hip to economize effort. 
So far treatment is only palliative, and on account of weakness, 
apparatus usually fails to improve locomotion. When power is 
lost, a go-cart, plenty of fresh air, massage, and resistive exercises 
assist in maintaining general health. In a case where contraction 
of the calf muscles produced talipes equinus, tenotomy of the tendo 
Achillis sufficed to restore the power of locomotion for many months. 
Straightening the knees by dividing contracted hamstrings has also 
been of advantage. 

In the British Medical Journal, for 1882, may be found an account 
of the only recorded recovery from pseudo-muscular hypertrophy. 




Fig. 40. — Climbing up on him 
self in pseudo-muscular hyper 
trophy. 



SPASTIC PARALYSIS. 

Spastic Paralysis, Little's Disease, Cerebral Palsies of Infancy. 

-Spastic paralysis is characterized by an increased excitability of 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 75 

the reflexes, and stiffening, a more or less tonic contraction of the 
weakened muscles. The paralysis may have the following dis- 
tribution: hemiplegia, diplegia, paraplegia, or monoplegia; there- 
fore it is of cerebral origin. Autopsies are uncommon, but they 
have demonstrated a large loss of brain, either on the surface or 
interior, supposedly from an extensive old hemorrhage. In many 
there is a loss of a large part of a lobe from the external pressure of 
hemorrhage from a meningeal artery. In many the intelligence is im- 
paired in varying degree from a grave idiocy to slight backwardness. 
Most are due to the cerebral hemorrhages of parturition, but some 
acquire the palsy in childhood from hemorrhage, thrombosis, em- 
bolism, or during the course of some acute infectious disease. 

Spastic paralysis is not uncommon and the prognosis is not good 
and is less encouraging with the greater degrees of mental impairment. 

Physical Signs. — The condition, when the child is brought to the 
orthopedist, is not a true paralysis of motion; the affected limbs are 
relaxed during sleep but at other times they are held awkwardly and 
attempts to use them or to give sudden passive movements evoke 
an incoordinate resistance, which yields to slow pressure of the 
hand. It is called spastic rigidity. 

Muscular atrophy is inconspicuous, but there are often distor- 
tions of the limbs from continually holding them in peculiar atti- 
tudes, and if of long standing the tissues may shorten so as to pre- 
vent a full range of motion of the joints. There is marked weak- 
ness. The knee-jerk is very lively and ankle-clonus easily started 
in the affected leg; in the arm a reflex like a knee jerk may some- 
times be obtained by tapping the triceps tendon just above the olec- 
ranon, and similar contractions by flicking with the finger over 
the bellies or tendons of affected muscles. 

Although all grades of idiocy accompany this affection, in some 
the mind is clear, and this influences prognosis, for it is useless to 
tenotomize and instruct in walking if the brain to use the feet be 
lacking; on the other hand children have been greatly improved 
mentally after walking was made possible, so the question of tenot- 
omy may be a hard one to decide. Epilepsy comes on in a number 
of them in adolescence; athetoid movements may also be present. 



76 ORTHOPEDIC SURGERY. 

Treatment is divided into muscle training, muscle division, 
and muscle transference. In a paraplegic the muscles which 
contract and interfere with locomotion are usually the adduc- 
tors and the gastrocnemius and soleus, producing a cross-legged 
gait with the heel raised and a clonus of the calf muscle, a con- 
dition which is relieved by strengthening the opposing muscles in 
a mild case, or by dividing the tendons, immobiliz r ng for a few 
weeks and using a walking retentive splint in severe ones. For 
the mild case such exercises as these: Lying on the back and 
straddling, this is done at first without resistance, later with a light 
weight attached to the ankle by a cord passing over the side of the 
table; turning the toes out may be taught by placing the heels to- 
gether and repeatedly rotating the feet with the body and legs 
in the same position; toe-raising can be learned by slow and re- 
peated attempts, at first aided with the hand. Exercises are of no 
use, however, if the spastic rigidity be great or if there be much 
mental impairment. 

Tenotomy of the tendo Achillis and plantar fascia has been of great 
benefit in curing the equino-varus deformity and is done exactly as 
for club-foot, see p. 29. Care must be had not to overcorrect much 
in the plaster bandage, which should be about at a right angle and 
should be worn two weeks and replaced by a walking apparatus 
which prevents toe-drop. Walking should begin at once and re- 
quires careful, patient teaching. 

Division of the adductors is best done by free open incision over 
the belly of the adductor longus made tense by abducting, giving 
a wide berth to vessels and nerves; it is advisable to excise a piece 
of muscle about two inches long to prevent reshortening and part 
of the adductor magnus may be removed by the same incision, that 
is the upper portion for the tendon of the latter is divided 
through a small separate incision a finger's breadth above the 
tubercle on the internal condyle of the femur. Much is gained by 
forcible stretching in abduction, branches of the deep external 
pudic artery and the internal circumflex branch of the profunda 
femoris may require ligature, and muscular branches. After ap- 
plying a superficial suture and dressing, the leg is kept in a double 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 77 

spica bandage of plaster-of-Paris in extreme abduction for a 
month. 

Muscle-stretching under full anaesthesia followed by fixation 
in plaster may be used for mild cases; the plaster bandage is to be 
worn three weeks and when removed it is a good plan to keep the 
feet apart with a short rod a foot or fifteen inches long loosely at- 
tached at each end to the ankles, and to wear the old plaster at night ; 
and exercises must be persevered in. 

For the arm in hemiplegics muscle-stretching under anaesthesia 
and myotomies have produced improvement, and in mild cases 
simple muscle-training has helped; this must form the essential 
part of the aftercure when fixation in plaster is finished. Better 
ultimate results have been obtained by tendon transference, however, 
and a number of different things have been done. 

Muscle Transference. — To correct incomplete extension of the 
knee, the sartorius has been transplanted into the tendon of the 
quadriceps extensor, also both sartorius and gracilis; these are not 
strong enough to give extension at first, but as Goldthwait has demon- 
strated they may grow strong with use. The hamstrings may be 
transferred forward; that is, the insertion of the biceps may be 
moved from the head of the fibula to the outer side of the quadriceps 
tendon, and the tendon of the semi-tendinosus into its inner border; 
this, of course, deprives the limb of part of its power of flexion and 
should be reserved for severe cases, with good hamstrings. 

In the forearm and wrist two operations have proved of value. 

Inability to supinate the hand may be improved by converting 
the pronator radii teres into a supinator, the operation is known 
as Tubby's operation. A four inch incision is made in the centre 
of the flexor surface of the forearm and the inner border of the 
supinator longus, reflected outward, exposes the belly and insertion 
of the pronator teres; this is divided at its insertion into the outer 
side of the radius and a silk guide-stitch is placed in the upper end; 
the dissection is continued close to the radius through the interos- 
seous membrane, then a second incision is made on the dorsum 
opposite the first so as to reflect the extensors carpi radialis brevior 
and longior towards the supinator longus, exposing the supinator 



78 ORTHOPEDIC SURGERY. 

brevis whose lower edge is freed to lay bare the radial origin of the 
extensor ossis metacarpi pollicis and the radius itself and expose 
the opening in the interosseous membrane made anteriorly; the 
silk guide-stitch is then passed through this opening and the prona- 
tor sutured to the outer side of the radius close to its old attach- 
ment; it then supinates instead of pronating. Supination is to be 
maintained in plaster for at least six weeks to get a firm union; a 
subperiosteal insertion may be better attachment than a periosteal 
one. 

For wrist-drop the flexor carpi radialis is cut at the wrist and 
attached to the tendon of the radial extensor close to its insertion and 
a similar transfer is made on the ulnar side. 

These operations may be done at the same sitting. After im- 
mobilizing six weeks in plaster, great care and pains must be taken 
with muscle-training exercises. Skilled use of the hands in agree- 
able work does much to prevent relapse, which is sometimes traced 
to discouragement and lack of use. Mild grades of feeble-minded- 
ness may prevent good use of the hand. 

OBSTETRICAL PARALYSIS. 

This form of paralysis is produced at the time of delivery by 
undue stretching of the brachial plexus or by pinching it between 
the clavicle and first rib. Prout studied these lesions excised at 
operation and showed that a "rupture of the perineural sheath 
takes place with hemorrhage into its substance." The amount 
of tearing apart of nerve bundles from hemorrhage varies and with 
it the prognosis for spontaneous recovery. Where there is stretch- 
ing and small hemorrhage rather than a tearing asunder the paral- 
ysis will be transitory, and improvement may be expected. 

The affection was first described by Duchenne twenty-five years 
ago. There are three types of the paralysis, as different parts of 
the plexus are affected. These types are recognized by peculiar 
positions of the arm, due to the nerve distribution. The types 
are the upper arm, the lower arm type, and paralysis of the whole 
arm. 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 79 

In the upper arm type, the conductivity of the fifth and sixth 
cervical nerves is interfered with, either by pressure or section, and 
the injury is either in the cords of the plexus or above it close to the 
intervertebral foramen. In this type muscles of the shoulder and 
upper arm are involved, the shoulder may be dislocated, but the 
forearm almost escapes. 

Bullard, in 43 cases at the Children's Hospital, found an involve- 
ment of the deltoid, biceps, brachialis anticus, supinator longus, 
supinator brevis, infra-spinatus, serratus magnus, coraco-brachialis, 
and teres major and minor. 

The arm hangs by the side in the position of inward rotation; the 
grasp is unimpaired; the hand supinates only half way; flexion at the 
elbow is weak, extension is not affected; the patient cannot raise the 
arm from the side nor rotate it outwardly; inward rotation is weak 
because the limb is held fixed in almost as much inward rotation as 
is possible; passive movements are free. This position is due to lack 
of antagonism and depends on three factors, inward rotation of the 
arm, extension of the forearm, and the weight of the hanging arm. 

In addition to the paralysis there may be adhesions around the 
scapula and adhesions to the capsule of the joint, or within the cap- 
sule. 

There is a shortening of the whole limb, and adhesions in the el- 
bow-joint may prevent complete supination. Dislocation of the 
head of the humerus is common, and the shoulder may be luxated 
forward or backward for which the pectoralis major or latissimus 
dorsi is largely responsible. A dislocation may occur in the el- 
bow, or there is frequently loss of complete extension, where from 
5 to 20 degrees of motion is lost. This may be due to several fac- 
tors. One had a backward dislocation of the head of the radius, 
another an imperfect growth of the olecranon and upper end of the 
ulna which had not developed sufficiently to enter the olecranon 
fossa, in another, there was a partial lateral dislocation of the joint, 
in another, the bones of the whole extremity showed great atrophy 
and shortening, in another anterior subluxation of the radial head 
had occurred. 

The lower arm type of paralysis, which is, however, rare, has 



80 ORTHOPEDIC SURGERY. 

been described by J. J. Thomas. In it, most of the muscles of 
the shoulder and upper arm are active and well nourished, while 
those below the elbow are paralyzed. 

In the third, or combined type of paralysis, there is more destruc-* 
tion of the cords of the plexus and paralysis of most of the muscles 
of the arm and shoulder. The condition is manifest immediately 
after birth although it may not be recognized for several days. 
The arm should be supported in a sling to prevent stretching the 
joint capsule and muscles. 

Treatment. — Massage and electricity are of use in lighter cases. 
Joints should be exercised that no permanent contraction may take 
place. External rotation of the shoulder and supination are the most 
difficult motions to preserve. When paralysis affects only certain 
muscles, muscle transference may be used. 

Nerve Grafting or Suture. — In a series of operations Clark, 
Taylor and Prout, of New York, restored voluntary power in three 
to five months after nerve suture in children as old as 8 and 10 years 
and in every one who survived there was some return of voluntary 
power. 

In some cases it was possible to locate the lesion in a portion 
only of one of the nerve trunks going to the plexus, and in one of 
these cases the fifth cervical anterior primary division and the outer 
part of the combined trunk were resected and sutured, with excellent 
result. 

Suture of the brachial plexus in the adult after stabs has seldom 
been performed and the return of voluntary power 8 and 10 years 
after birth was a surprise to many who thought that after 2 or 3 
years, regeneration of a nerve trunk could not occur. 

Spitzy, in July, 1905, operated on a boy of 12 years, with obstet- 
rical paralysis of the left arm. The prominent symptoms were 
paralysis of the radial nerve, and, accordingly, the radial nerve was 
connected with the median nerve. A slip from the median nerve 
was inserted at the elbow into the radial, and the point protected 
from cicatricial growth by surrounding it with a sheath made from 
a dog's artery hardened in formalin. A light bandage maintained 
the flexed position of the elbow. In a week the wound had healed, 



DISEASES CAUSING DEFORMITY ORIGINATING BEFORE BIRTH. 8 1 

and in six weeks, light massage was begun. In two months slight 
movements were noticed extending the fingers and in six months 
almost all the extensor muscles had regained power. 

Tubby has also transplanted the outer cord of the brachial plexus 
into the middle cord for paralysis of the Erb-Duchenne type. 

In rare cases nature unaided brings about a cure late. Recov- 
ery of voluntary power may keep on slowly, almost imperceptibly, 
until complete or very nearly complete power returns to the arm. 
Sometimes the outward rotators of the humerus are not really paral- 
yzed, but they are kept on the stretch by the powerful inward ro- 
tation of the pectoralis major and latissimus dorsi. Much benefit 
has been derived in a few instances by the open division of these 
strong tendons close to their insertions in the bicipital groove, and 
maintaining the arm in extreme outward rotation of the shoulder 
by means of the plaster bandage or wire splint. They should be 
divided thoroughly by open incision. 4 

To restore the lost power to flex the elbow two slips from the tri- 
ceps tendon may be brought forward and attached to the insertions 
of the biceps and brachialis anticus muscles. This seems worth 
trying although some say that one muscle cannot be innervated to 
pull separately on opposite sides of a joint. 

Jones' Operation. — A different procedure has been done by 
Robert Jones. Aiming to maintain the flexed position of the elbow, 
he removed a diamond-shaped flap of skin from the bend of the 
elbow and sutured the edges so as to fix the elbow in a position of 
acute flexion, so that the hand can be of use for with the elbow 
extended it is almost useless. In two patients, aged 3 and 4 years, 
he found in less than 6 months after operation power was returning, 
and in less than 12 months restoration was almost complete. 



PART II. 

DEFORMITIES DUE TO BONE-GROWTH 
INFLUENCED BY EXTERNAL FORCES. 



CHAPTER VII. 

IRREGULAR SKULLS; LATERAL CURVATURE OF 
THE SPINE. 

IRREGULAR SKULLS. 

Influence of Gravitation. — Babies are often brought to the ortho- 
pedist for a disproportion or asymmetry in the head; one side of the 
forehead is prominent, the other recedes, one ear is higher and slightly 
in front of the other, and if one looks down on the top of the head 
the shape is far from regular. This distortion is due to the action of 
gravity on the loose semi-membranous skull before the sutures ossify. 
If the babe is left lying in one position a flattening takes place at that 
part of the head which is pressing on the bed and a corresponding 
flat place diametrically opposite, w T hile some bulging appears be- 
tween. If the baby always lies in the same position this flatten- 
ing and bulging little by little increases and all the cranial bones move 
slightly, including the orbit and the ear, so that the head becomes 
noticeably awry. The treatment is simply to have baby lie on the 
other side so as to press the bulging part in; and later to sleep on each 
side alternately; one is indeed fortunate if the deformity is corrected 
before synostosis has taken place, and the deformity becomes fixed. 
Even then a certain amount of correction occurs through subsequent 
growth. The irregular shapes of men's skulls may be seen at the 
hatter's, whose machine for fitting the hat to the head marks out 
an outline of the skull. 

But this is not the only cause of irregularity in the shape of the 
skull; distortion and asymmetry arise from growth restricted by 
a short sterno-mastoid muscle in congenital torticollis (see Chap- 
ter XIX). 

Anatomists have shown that any distortion of the neck or of the 
occipital portion of the skull is followed by a twist of the face. Pro- 

85 



86 



ORTHOPEDIC SURGERY. 



fessor Dwight, of the Harvard Medical School, has studied in the 
Warren,', Museum the asymmetrical crania with the anomalies 
in the cervical spine and found that they may be divided into three 
classes: (i) Those associated with a diminution of the number of 
cervical vertebne; (2) those with fused cervical vertebrae; (3) those 

associated with union of 
the atlas and occiput, 
either by fusion or by 
an intervening paramas- 
toid process with or 
without fusion. 

The cause of oblique 
growth of the skull and 
face is little understood. 
Dwight thinks any in- 
equality in the level of 
the condyles of the oc- 
ciput or the habitual 
advancement of one 
condyle ahead of the 
other may make the 
skull grow awry, for it 
brings into play a na- 
tural tendency of the 
body to correct an un- 
balanced condition. 
Suppose that anomalies 
in the cervical spine 
cause the head to look 
to the left, the right 
cheek is then more advanced and higher than the left; in order to 
look straight forward the head moves and the spine is twisted; 
little by little this twisting is taken up by the growth of the bones 
of the face and skull and in time a twist occurs in the skull so 
as to bring the left cheek farther forward and to direct the line of 
vision of the two eyes horizontally by a change in the direction 




Fig. 41. — Skull showing irregular cranium. 
(Warren Museum.) 



LATERAL CURVATURE OF THE SPINE. 87 

of the orbits; a similar change makes the line of the teeth hor- 
izontal and to accomplish this the direction of all the sockets in 
the jaws is altered. Still other factors are said to mould the face 
and skull into irregular shape. If one eve is very much better than 
the other it will instinctively be brought to a position where it can 
be used to more advantage, or a deaf ear may cause a displacement 
of the head and later compensatory change in shape through growth. 

LATERAL CURVATURE OF THE SPINE. 

Lateral curvature of the spine, Scoliosis, in German Skolio- 
sis, Seitlicher Ruckgratsverkrummung, in French, Deviation lat- 
eral la taille, Italian, Scoliosi, Spanish, Escoliosis, is a lateral devia- 
tion constantly maintained of the spinal column from the median 
sagittal plane of the body. It does not include mere postures, side 
bendings temporarily assumed or habitually taken which can be 
easily corrected by voluntary effort and have produced no struc- 
tural change; these are called postural curvatures or mal postures; 
their correction is of great importance for they may lead to true 
lateral curvature in time. 

Lateral curvature is one of the commonest deformities; rarely 
seen at birth, but few are noticed before the seventh year when it 
ben omes progressively more common, till fourteen, fall- off stead- 
ily till eighteen, remains uncommon till twenty-two, and rarely 
develops after. Failure of parents to notice the beginnings leads 
one to the belief in an onset earlier in childhood. Recent investi- 
gations by Schulthess and Spitzy show that scoliosis is not uncom- 
mon in the ilorid stage of rickets (early childhood;, and Bohm's 
radiographs of lateral curvatures show that a large proportion are 
of congenital origin, so that it is probably latent more commonly 
in early life than has been previously believed. 

Explanation of Descriptive Terms. — Certain terms used in 
describing the deformities of lateral curvature need a word of 
explanation. 

A deviation is present whenever the spine fails to run a straight 
and vertical course; a lateral deviation if it deviates to one side. 



88 ORTHOPEDIC SURGERY. 

Inclination means that it leans or inclines to one side, or tips. 

When the shoulders, instead of being over the base of the spine, 
are off to one side there is a lateral displacement. 

Rotation is a term used in two senses, the anatomical and the 
clinical: anatomically it means a turning aside of the front of the 
vertebra from the straight forward direction it should face; clinic- 
ally it is made to refer to the changed appearance of the back due 
to rotation, that is, to the prominence on one side and the flattening 
on the other caused by the ribs or transverse processes turning with 
the vertebrae and displacing the muscles of the back. The angle 
of rotation is the amount of this turning aside from the normal 
sagittal plane. 

Torsion means twisting within the bony structure of a vertebra 
from distorted growth. In this country it has also been used in 
a clinical sense to mean that the line of the shoulder tips and that of 
the hips are not parallel as they should be, in other words that the 
shoulders are twisted on the hips, that if an imaginary line between 
the hips were projected upward vertically one shoulder would be 
back of it and the other in front. It seems better not to use the 
term in its clinical sense. 

Lateral Curves. — In a spine there may be found one or more 
lateral curves, a condition spoken of as single, double, or treble curves; 
also called primary and secondary curves or simple and complicated. 
A curve may be sharp or flat, angular or bowed, long or short, and 
right or left (meaning convex to the right or left). In complicated 
curvatures each component curve has to take a direction different 
from the adjacent; e. g., a right curve with a left one or between 
two left ones. A single curve of the whole column may exist and 
be called a total curve. A curve may be according to location, cervi- 
cal, cervico-dorsal, dorsal, dorso-lumbar, lumbar, lumbo-sacral, even 
slight sacral curves have been described. The normal physiological 
antero-posterior curvatures may or may not be affected by a lateral 
curvature; it may increase, diminish, obliterate, or reverse any 
normal or physiological curve, or it may not influence it at all. If a 
kyphotic deformity is the prominent feature, the curvature is called 
a kypho-scoliosis; it may be a right dorso-lumbar kypho-scoli- 



PATHOLOGICAL ANATOMY. 89 

osis, a left lumbo-dorsal lordo-scoliosis, etc. Clinically patients with 
lateral curvature are classed as the flexible and the stiff or struc- 
turally deformed. Schulthess has three clinical grades, first, those 
who can by voluntary effort straighten and correct the curve, sec- 
ond, those who can improve it, third, those who by their own efforts 
cannot improve their attitude. 

The Growth of the Physiological Curves of the Spine. — The 
normal or physiological curves of the spine develop in childhood, for the 
infant at birth has only the lumbo-sacral angle to interrupt the spine's 
straight course. It is an extremely flexible spine because not only 
are the intervebral discs very large, the bodies themselves are still 
largely soft embryonic cartilage. Early 
in infancy traces of lordosis may be 
seen, both in the cervical and lumbar 
spine, and at three the dorsal region 
may acquire a beginning kyphosis. 
Tracings of the spines of living children 
made yearly by Schulthess show in- 
terestingly the development of these 
curves. Ossification in the spine is 
slow; though it begins early (the 
seventh week) the vertebrae keep on 
growing and adding epiphyses till the 

twenty-second year; and the last ones 

r 11 -. 1 , r™ t 1 Fig. 42. — Infant's spine. 

finally unite ten years later. 1 he old r 

man's spine is the reverse of the infantile; it is bowed, its move- 
ments restricted, the intervertebral discs are thin and wasted, and 
the bones light, thin, hard and brittle. 

PATHOLOGICAL ANATOMY. 

Pathological Anatomy. — The study of pathological material has 
been confined to the severe forms; their dry bones have been care- 
fully studied, the ligaments, muscles, and the internal organs have 
been studied by only a few; congenital curvatures associated with 
spina bifida and rhachischisis have been described, and recently some 




90 ORTHOPEDIC SURGERY. 

cases of numerical variations of the spine. To Schulthess we owe 
much for compiling this material. 

Museum specimens never show changes indicative of bone disease; 
on the contrary the modifications of form and structure suggest 
the prolonged effect of pressure and strain on growing bones. The 
spine curves to one side in some part of its length, or it curves to 
one side in one part and to the opposite side above or below, or 
both above and below; there is a deviation of vertebrae away from 
the median plane. Seen in front this is greater than behind, 
that is the column of bodies deviates more than the arches. In 
severe curves the sacrum and even the coccyx may deviate. The tho- 
rax and pelvis are often distorted. The vertebrae in the summit 

.... of the curve are rotated; they 



turn their bodies to the convex 
side of the curve. Though im- 
perfectly understood it seems 
that the greatest amount of over- 

Fig. 43. — Diagram of the wedge and hang or of flattening occur in 
the lozenge vertebral bodies, the dotted those ; ^ hibit the 

outline is the normal. r 

most rotation. 

Individual vertebrae show changes in their bodies, arches, proc- 
esses and in the relations these bear to each other. 

Vertebral Bodies. — The bodies in the apex of a curve, from two 
to five in number, are lower on the side of the concavity than on 
the convexity of the curve. They are wedge shaped and are styled 
wedge- or apex- or rotation-vertebrae, for they are rotated the most. 
They are widened out on one side by an outgrowth of their superior 
and inferior surfaces; and it is always on the concave side as if they 
were wax and their diminished height had been produced by melting 
and broadening them by pressure. Either one or both surfaces may 
be pared down, and the intervertebral discs are similarly dis- 
torted and bulge out on the concave side more than the bones do, 
concealing the bony outgrowth. 

The bodies of the vertebrae immediately above and below them as 
far as the end of the curve, exhibit a very different distortion of 
structure; they are called oblique, torsion, or lozenge-shaped vertebrae. 



PATHOLOGICAL ANATOMY. 9 1 

The top and bottom surfaces are in parallel planes, but they are slightly 
displaced laterally on each other so that if viewed from the front the 
outline of the body is no longer rectangular but lozenge shaped; and 
the tops and bottoms have twisted upon each other, torsion- vertebrae. 

As each of these vertebral bodies is both lozenge shaped and 
twisted in the same direction, they build up together in the column a 
curve of which the wedge-vertebrae form the apex, and one can 
readily see that both the lateral deviation and rotation are due to the 
asymmetrical shapes of these bones, a crooked column of crooked 
bones; and that the displacements of a vertebra upon its neighbor, 
due to the flexibility of the intervertebral discs, and movements of 
the joints, play no part in its formation; hence these are structural 
or fixed curvatures. The obliquity and torsion of the lozenge verte- 
brae is in the reverse direction above the apex and so causes a gradual 
approach to the normal direction of the spinal column above. The 
twist of these oblique vertebrae varies in different parts of the column 
and is greatest where two curves meet and least near the apex; tor- 
sion is often indicated by little oblique ridges on the front and sides 
of the vertebral body. 

The spinal foramen undergoes a change of outline; in the dorsal 
spine it loses its roundness and is ovoid, with the point on the side 
of the concavity; in the lumbar the triangular shape is altered by 
rounding off the angle on the side of the concavity. 

The Arches. — The arches too are distorted; the pedicles deviate 
both from their normal backward direction and from their normal 
degree of inclination, and their changes affect the rest of the arch 
and all the processes. 

The Pedicles. — Excepting one or two vertebrae in the summit 
of the curve all the pedicles in the curve are distorted. Viewed from 
the side the pedicle of a wedge-vertebra is on the convex side directed 
more upward and on the concave side more directly backward than 
normal; seen from on top the convex pedicle has a backward, the 
concave, a backward-and-outward direction. In the oblique-verte- 
bra there is less difference between the right and left pedicles, but 
they are more nearly level below, and more steeply inclined above 
the summit of the curve. The length, breadth, and height of a 



92 ORTHOPEDIC SURGERY. 

pedicle may also be changed from the normal; the concave pedicle 
of a wedge-vertebra is always broadened to correspond with the 
one-sided widening of the tops and bottoms of the body; its ver- 
tical height is less in the dorsal, and greater in the lumbar region ; 
dorsal pedicles are long on the concave and short on the convex side, 
hence the paradox "both the body and the spinous process are turned 
toward the convexity," only true of dorsal vertebrae. 

The articular processes are altered because of the displacement 
produced by the abnormal pedicles and from changes in their artic- 
ular facets due altered statics and growth. On the concave side 
they are crowded together, the facets are enlarged, deepened and 
broadened, and the cartilage thickened; on the convex the facets 
are smaller than normal and closer to the tip of the process; one 
infers that the joints on the side of the concavity were more used 
and bore greater weight; they are also the oftenest ankylosed. 

The transverse processes tend to remain more truly horizon- 
tal than the rest of the spine; in the dorsal region their rib attach- 
ments restrict and modify this, but in lumbar spines, with severe 
deformity, where this part of the spine sometimes inclines almost 
horizontally the distortion of the transverse processes is extreme and 
they are directed up and down with reference to the long spinal 
axis, though in reality they are parallel to the horizon. 

The lamina are not distorted to any extent. 

The spinous processes turn as already noted to the side of the 
convexity in the dorsal spine. There they also are depressed so 
that they overlie and touch each other like shingles on a ridge which 
slope, as do also the laminae. In consequence of the difference in 
elevation of the two pedicles and their different lengths the spin- 
ous process, which is the real point of union of the two halves of 
the arch, must twist. In the lumbar spine the angle which the proc- 
ess makes with the laminae on the two sides is not equal, being 
smaller on the convex than on the concave side, as if a feeble at- 
tempt were made by nature to have the paradox hold good for the 
lumbar as well as the dorsal spine. 

Probably muscle pull has much to do with the distortion of the 
transverse and spinous processes, but this is imperfectly understood. 



THORAX AND PELVIS. 93 

f 

THORAX AND PELVIS. 

Thorax. — So far conditions in the vertebrae only have been con- 
sidered; the thorax and pelvis are so intimately attached that they 
are regarded as a part of the spine itself; they are frequently de- 
formed in lateral curvature. 

Rib Joints. — The joints between the heads of the ribs and the 
vertebrae are of two kinds; those between the head of the rib and the 
side of the body and those between the side of the rib and the trans- 
verse process. Both are, in severe deformity, displaced forward on 
the concave side and back on the convex side of the vertebral body ; 
they are faintly indicated on the concave side, but deeply sunken on 
the side of convexity, and the ligaments are lax. 

Rotation oj Thorax. — In lumbar scoliosis the only change in the 
thorax would be a slight rotation of the whole thorax. In dorsal 
scoliosis the whole thorax is usually displaced laterally on the pelvis 
and its structure distorted. It has to maintain more nearly a normal 
position than does the spine. Its diagonal diameter from behind on 
the convex to in front on the concave side is lengthened and the other 
diagonal shortened, because of a sharper angle of the ribs on the side 
of convexity, and a flattened angle of the corresponding rib oppo- 
site; in front the ribs and their cartilages run with little curve to the 
sternum on the convex side, but are often on the side of their con- 
cavity bent to a sharp angle near the joining place of the rib and 
cartilage. These rows of prominent rib angles make a hump, the 
so-called rippenbuckel, rib-hump of the Germans, who refer usually 
to the posterior rib-hump. The ribs are more separated and more 
steeply inclined on the convex, more crowded and more nearly hori- 
zontal on the concave side. In some complicated curvatures as 
many as three curves with rib-humps may be seen. The sternum 
moves but little from its normal site; it may be displaced laterally 
or the tip may turn to either side, or it may rotate on its long axis, 
tipping the side toward the concavity forward under the skin. 

Shoulder-girdle. — The shoulder-girdle shares in the changes in 
the thoracic wall as its position depends on the three things, the de- 
formity of the thorax, the weight of the arm, and muscle-pull. A rib- 



94 ORTHOPEDIC SURGERY. 

hump forces the scapula away from the spine and, if high in the 
thorax, causes it to rise; but the scapula may lie sagittally instead 
of frontally, or sometimes it may be forced back to overlie the spines. 
The clavicle is occasionally more curved on one side than the other. 
The Pelvis. — The sacrum and pelvis are frequently distorted ; in 
low lumbar curves the sacro-lumbar junction is often the apex of 
curvature ; therefore one may see a decreased height of the first sacral 
on the side of the concavity with broadening on that side of the base of 
the sacrum, and a slight rotation of both the body and wings. Schult- 
hess describes a sacral curve with apex at third and fourth sacral 
and deviation of the coccyx. Sacral distortions are slight and are 
detected by sighting along the front of the bone. In low curves 
with a sacral distortion the pelvic diagonals are unequal; in a low 
left lumbar curve the left posterior to right anterior is the longer. 

SOFT PARTS. 

The Muscles. — Muscle in disuse atrophies and turns to fat ; under 
increased demands it hypertrophies; when it rubs over the surface of 
a bone it forms tendon or fibrous tissue; permanent shortening oc- 
curs as an adaptation to an approximated position of its ends. All 
these changes are found in the severest scoliotics at autopsy, but 
the muscle changes of slight grades are unknown. The advanced 
changes described by Phelps and Schulthess seem altered beyond 
possibility of improvement. 

Internal Organs. — The shortening of the trunk, the distortion and 
decreased capacity of the pleural and abdominal cavities affect both 
the growth and function of the organs. 

Lungs. — Bachmann found from records of 182 autopsies on scoli- 
otics that many have consumption, and many die of it, 28.3 percent 
of the severe cases, and 66 percent of the milder ones. The chest ca- 
pacity is diminished most in the convex side when there is a marked 
rib-hump. Clinical corroboration of this fact is furnished by Mosse, 
who noted apex infiltration in 60.2 percent of scoliotic children; and 
by Kaminel and Zade, who found it in 73 percent of scoliotic women. 

Adhesive pleurisy was found in 74.6 percent of Bachmann's autop- 



SOFT PARTS. 



95 



sies; in 31 percent there was atelectasis of lungs, and in 23 percent 
pneumonia. 

Heart. — The heart, usually displaced upward and crowded to the 
front, is often enlarged both by hypertrophy and dilation; the right 
heart was affected in 56 percent, the left in 17.5 percent, and both 
right and left in 25.9 percent. The aorta and the great veins are 
not much distorted but 
occasionally run an un- 
usual course. The eso- 
phagus also varies but 
little from its normal 
course if the curve be a 
long one. 

A bdo'minal Viscera . — 
The diaphragm is pushed 
up high and, of course, 
follows the inclination of 
the thorax. The abdom- 
inal viscera are, in conse- 
quence of decreased 
space, crowded downward 
and forward and the small 
intestines occupy the cav- 
ity of the pelvis; the trans- 
verse colon may take an 
almost vertical course if 
there is much lateral dis- 
placement of the trunk 
to the right. The liver in 

right curvatures is crowded over to the left and the left lobe has a better 
chance to grow large. The right kidney in right curves is displaced 
up, the left down; the latter is oftener the seat of pathologic change: 
out of 180 observations, Bachmann found 14 cystic kidneys, 31 with 
granular atrophy, 18 with simple atrophy, and 6 hydronephroses. 

The spleen may be displaced upward; perisplenitis, atrophy, and 
cyanotic induration have been observed. The stomach, owing to 




Fig. 44. — Specimen in Warren Museum show- 
ing displacement of the aorta in severe right 
dorsal kypho-scoliosis from its place on the 
spine to the left ribs. 



9 6 



ORTHOPEDIC SURGERY. 



the crowding downward and forward of the liver and with it of 
the duodenum, has a more vertical direction from the cardia to the 
pylorus. 

THE DEFORMITIES IN THE LIVING. 

The deformities we may divide into five classes: The congenital, 
including those due to numerical variation of the spine whose de- 
formity does not appear until puberty, or thereabouts; the func- 
tional, acquired through faulty habits of posture — the so-called 
school scoliosis; those due to diseases of the bones — rickets, os- 
teomalacia, etc.; those due to thoracic diseases, such as empyema, 
enlargement of the heart, etc.; and the paralytic. It may turn 
out, as Bohm confidently predicts, that the second class should be 
included in the congenital, or, as he calls it, the idiopathic class in 
contradistinction to the other classes which are all symptomatic 
of deformities or diseases elsewhere. 

Any part of the column may be affected, the curve may be ca- 
pable of self-correction, of improvement, or it may be fixed so that 
we get no improvement. It is important, therefore, to know first of 
all about the cause of the lateral curvature, and secondly about 
the grade or capacity for correction. Anatomically there are cervico- 
dorsal, simple dorsal, dorso-lumbar, lumbar, complicated dorsal 
curves, and total curves. 

The relative frequency of the different clinical forms is shown in 
the following table of Schulthess' from JoachimsthaPs Handbuch 
der Orthopadischen Chirurgie : 





Totals. 


Principal 
Forms. 


With Compen- 
satory Curves. 


Without Compen- 
satory Curves. 




Left. 


Right. 


Left. 


Right. 


Left. 


Right. 


Total scoliosis, . . . 


175 


156 


19 


6 


I 


150 


18 


Cervico-dorsal scoliosis, 


42 


26 


16 


17 


7 


9 


9 


Dorsal scoliosis, . . 


217 


112 


I05 


10 


32 


102 


73 


Lumbo-dorsal scoliosis, 


221 


182 


39 


49 


17 


133 


22 


Lumbar scoliosis, . . 


134 


71 


63 


3i 


41 


40 


22 


Dorsal scoliosis, com- 
















plicated, .... 


348 


66 


282 


66 


282 





— 




**37 


3i3 


524 


179 


389 


434 ■ 


144 



THE DEFORMITIES IN THE LIVING. 



97 



TOTAL SCOLIOSIS. 



We speak of a total scoliosis when a single long flat curve is dis- 
covered with the apex near the middle of the whole spine, the lower 
dorsal region. It implies both a curve 
of the spine, and one of the whole body 
from head to foot, with the pelvis dis- 
placed toward the side of convexity. 
These curves are slight and flexible, 
and it may be a simple malposture, or 
an early stage of development of either 
a left-lumbo-dorsal curve, a left-lumbar 
right-dorsal curve, or a simple com- 
mencing right or left dorsal curves. In 
fact they may be divided into true total 
curves and false. The attitude may be 
seen by the illustration, Fig. 45. It is 
much more common on the left side than 
on the right. The rotation in total 
scoliosis shows, when the patient bends 
forward, a prominence on the side of 
the concavity instead of the convexity 
of the spine, even when a back shows 
a very slight scarcely appreciable curve. 
This difference is distributed in the 
whole back, including the shoulders. 
Right-sided total scoliosis is rare, and 
Schulthess believes that it only exists 
as an early stage of other curvatures. 

Total curvature is a little more fre- 
quent than simple lumbar curvature 
and constitutes about 15 percent of all 
cases of lateral curvature. The apex of the curve lies at about the 
ninth or tenth dorsal spine but it may be as high as the sixth or as 
low as the second lumbar. In the rare cases of right convex total 
scoliosis, Schulthess found the apex at the seventh dorsal. Hess 
7 




Fig. 45. — Total curve with 
plumb-line. (Children' s 
Hospital.) 



98 ORTHOPEDIC SURGERY. 

found that 70 percent of his cases of total scoliosis which were kept 
under observation for a long time remained unchanged in form. It 
is commonest from 8 to 10 years of age, and is more frequent in boys 
than in girls. 

LUMBAR SCOLIOSIS. 

The row of spinous processes describes a short curve with its 
apex in the lumbar column, and the trunk is displaced sharply 
toward the side of the convexity, consequently, the re-entering angle 
at the waist is flattened on the convex side and much increased on 
the concave; hence parents speak of a child's hip ''sticking out." 
There is marked rotation of the vertebra.', and in forward bending, 
the prominence in the loins is on the side of convexity, the flattening 
on the side of concavity. In most cases, the 
line of the spinous processes bends sharply 
from the vertical as it leaves the sacrum and 
soon curves toward the vertical again — a 
direction which it continues to maintain. In 
other cases the sacrum itself is not vertical 
Fig. 46. — Total scoliotic but leans to the side of the curvature, and in 
rt^Hght™ STtf a™*er class of cases the upper part of the 
concavity. {Children's column gradually approaches or intersects 
Hos P ltaL "> the vertical erected at the fold of the nates. 

Antero-posterior curves of the spine may be present; the patient may 
have a round back or a flat back; marked lordosis is sometimes seen 
in cases of rhachitic origin. The lumbar curve is frequently an 
accompaniment of right dorsal curvature. As a rule these curves 
occur in older children. Schulthess found the age of the youngest 
to be 7 years, the oldest 28 years, and the average age, 14 J years; 
the greatest number of cases occurred between the ages of 12 and 
15 years. 

LUMBO-DORSAL SCOLIOSIS. 

This form represents a fairly large proportion of all cases. The 
clinical picture often varies but little from the lumbar or from the 
dorsal cases where the curve has reached advanced proportions. 




THE DEFORMITIES IN THE LIVING. 



99 



We notice first a change in the waist line, an accentuation of the re- 
entering angle on the side of the concavity and often a lateral over- 
hanging of the ribs and trunk on the side of the convexity; but the 
short sharp curve at the top 
of the sacrum, which is so 
common in the lumbar form 
of scoliosis, is wanting. The 
apex is around the tenth dor- 
sal, and the shoulder on the 
side of the concavity is often 
lower. Rotation is present 
and is noticeable on bending 
forward at the level of the 
apex of the curve, the back 
being prominent on the side 
of convexity and flattened on 
the side of concavity. Schul- 
thess has seen reversed rota- 
tion but it is very rare. The 
shoulder on the side of con- 
cavity is displaced backward, 
that is, the rotation is often in 
an opposite direction from 
what it is in the lower part of 
the thorax. 

Etiologically these simple 
lumbo-dorsal curves divide 
into three classes: Slight 
curves, usually due to func- 
tional scoliosis, and the severer 
forms due to paralysis or rick- 
ets. Rhachitic cases usually 

have marked lordosis, while paralytic backs are bowed backward. 
The latter are curves of long radius, and in the lighter forms, 
radiographs of the spine look quite straight. The most deforming 
type is left lumbo-dorsal kypho-scoliosis from rickets. 




Fig. 47. — Left lumbo-dorsal, a long flat, 
curve with rotation on side of convexity 
(left lower ribs). {Children's Hospital.) 



IOO 



ORTHOPEDIC SURGERY. 



DORSAL SCOLIOSIS. 
Simple dorsal scoliosis, according to Schulthess, occurs in 19 per- 
cent of his 1 140 cases. The deviation laterally is seen in the middle 
or lower dorsal column without any appreciable curves elsewhere, 
and without inequalities on forward bending which would lead 
us to suspect a secondary lumbar curve. The apex of the curva- 
ture, usually between the sixth and eighth, is associated with a 
certain amount of kyphosis, with the phenomena of rotation at 
. .;,,= v , ? the seat of the curve shown by prominent 

ribs on the convex side and flattened ones 
on the concave. The shoulders, however, 
may be twisted in the reverse direction so 
that the shoulder on the side of concavity 
is back of the other. Lateral displacement 
of the trunk may be very slight or wanting. 
The curve is sharp and the parents notice it. 
In many cases forward bending does not 
accentuate rotation of the ribs, but seems to 
make more marked the lateral deviation of 
the spines at the apex of the curve. This 
occurs only in cases of slight and moderate 
curvatures; in the severe forms the de- 
formity from rotation of the vertebrae is 
prominent, and these cases are of rhachitic 
origin, according to Schulthess and Spitzy, 
and begin early in childhood. 
Dorsal kypho-scolioses often suggest Pott's disease and may 
be mistaken for complicated curves on account of the length of 
the dorsal curve and the shortening of the trunk. Schulthess also 
calls attention to the fact that some right-dorsal-left-lumbar curva- 
tures, in the course of years, become single dorsal curves with marked 
trunk shortening. The reverse is also true, a simple dorsal curva- 
ture in the course of years may develop a secondary lumbar curve; 
but this does not always occur. 

There is a definite specific character to the simple dorsal curve, 
whether right or left. 




Fig. 48. — Left dorsal 
kypho-scoliosis with short- 
ened trunk. (Children's 
Hospital.) 



THE DEFORMITIES IN THE LIVING. 



IOl 



CERVICO-DORSAL SCOLIOSIS. 
Cervico-dorsal curves present a typical clinical picture — they are 
sharp, short curves, usually convex to the left with the apex in the 
neighborhood of the third or fourth dorsal spine, with strong devia- 
tions of the trunk and considerable overhang which is quite char- 




Fig. 49. — Right dorsal scoliosis with amesial pelvis. {Children' 's Hospital.) 



acteristic of this form of scoliosis; the head is always thrust forward 
and usually leans a little toward the concave side; the sides of the 
neck are markedly altered and there is a prominence sideways and 
backward on the convex side and the shoulder droops on the concave 



102 



ORTHOPEDIC SURGERY. 



side; the arm hangs from a shoulder which is pushed forward by the 
convexity and the whole trunk seems displaced toward the concave 
side, which may be demonstrated by a plumb line from the cleft of 
the buttocks which shows the head displaced almost entirely on the 
concave side. Even in slightly developed curvatures, the character- 
istic high forward position of the shoulder-blade is always seen. 

Schulthess regards these 
cases as rhachitic. A sharply 
angular rib-hump is usually 
noticed, which pushes the 
scapula out of place upward 
and forward so that the plane 
of the scapula is more nearly 
sagittal than frontal and the 
angle of the scapula is often 
very prominent under the 
skin; on the concave side the 
reverse takes place — the scap- 
ula is lowered and swings in- 
ward so far that it may touch 
or overlap the row of spinous 
processes. The extreme lateral 
deviation seen in these cases 
may be accounted for by the 
endeavor to balance and keep 
the head straight with refer- 
ence to the horizon. 




COMPLICATED DORSAL 
SCOLIOSIS. 



Fig. 50. — Right-dorsal-left-lumbo-dorsal 
curvature with marked rotation. {Chil- 
dren's Hospital.) 

Patients with complicated 

dorsal scoliosis present two or more lateral deviations simultaneously. 

This was formerly regarded as the only typical form of scoliosis, 

because the physician was not consulted until the curvature had 

become a very severe deformity. From a mathematical standpoint 

it would seem as if dorsal curvatures should be compensated for by a 



THE DEFORMITIES IN THE LIVING. 



103 



curve in the reverse direction above and below ; but this is not always 
the case. Not only does the deviation laterally of the line of spinous 
processes show the presence of one or several complicated curves, 
but the appearances from rotation which are seen on forward bending 
give a strong hint as to the true position of the column. 
This hint is especially useful in establishing the pres- 
ence of complicated curves of slight degree; and any 
flattening of the back on one side and prominence on 
the other side which is reversed in the upper and 
lower portions of the back is to be heeded as if one 
had to do with a scoliosis with convexities toward the 
prominences. 

The difference is usually appreciable in the position 
of the shoulder-blades — that on the convex side wan- 
ders back toward the vertebral column and appears 
abnormally prominent; the opposite shoulder-blade on 
its flattened thorax is displaced far outward and 
forward and tips so that its lower angle is prominent, 
and by this means compensates for a certain amount 
of flattening of the chest. 

When the dorsal deformity is high, the shoulder- 
blade is pushed up on the convex side as in cervico- 
dorsal cases; the trunk may center properly over the 
sacrum or be displaced laterally. Apparent symmetry 
is often obtained owing to the reverse direction of 
the curves. Besides there is deviation in an anterior- 
posterior direction for few complicated dorsal curves 
have a flat back. The back may give the impression 
of a total lordosis and the row of spinous processes 
appear as a deep furrow between the shoulder-blades, 
so that it is difficult to make out the lateral curves, 
but in the forward bending position the rib-hump is 
prominent, not in the erect position. There is always marked rota- 
tion in the lumbar column in an opposite direction to that seen in 
the dorsal, and often there is a sharply localized bend of the column 
in the neighborhood of the lumbo-dorsal junction. Localized lordotic 




Fig. 51. 
Lateral cur- 
vature with a 
hollow round 
back. (Chil- 
dren' s 
pi tat.) 



Hos- 



104 ORTHOPEDIC SURGERY. 

bending may be seen in the dorsal segment combined with the de- 
formity of rotation and considerable lateral deviation of the trunk. 
In another set of complicated curvatures marked kyphosis is present 
from the very beginning and there is relatively little development of 
side deviation. 

These different types of deformity are combined in most varying 
pictures. There are all sorts, varying from a scarcely noticeable 
suggestion of a double curve to the severe structural deformities 
with lateral displacement, trunk shortening, inclination of the lum- 
bar column to the horizontal, marked rotation, kyphosis with over- 
hanging rib-hump and shortening of the trunk. 

The kypho-scoliotic cases always present a deformity of great 
severity, as the sharp prominence of the rib-hump, the shortening of 
the trunk with the descent of the ribs within the crests of the ilia, all 
indicate very severe grades of deformity. 

This form is, however, very uncommon among school children. 

The Causes of Lateral Curvature. — The many causes of scoliosis 
fall into four groups; the congenital, the osteogenous, the mechanical, 
and the functional. 

Congenital Scoliosis. — Here (see Chapter II, page 16), there are 
congenital deformities due to numerical variations in the spine, and 
malformations like spina bifida which give rise to lateral curva- 
ture. These congenital scolioses unrecognised for many years, 
are now subdivided into the deformities which are appreciable at 
birth and those which develop later. More study with the radio- 
graph is essential in these cases. 

Schulthess describes several cases arising from spina bifida. 
In one there was a rudimentary formation of the third lumbar 
vertebra associated with spina bifida, producing a left lumbo- 
dorsal curve; she had also an unequal length of legs and she 
kept one knee bent, but by straightening both knees the curve 
could be changed into a right lumbo-dorsal curve. The second 
case, a 13 -year old child, had a sharp, right-convex dorso- 
lumbar curve due to spina bifida. Another child with congenital 
elevation of both shoulder-blades had spina bifida occulta in the 
cervico-dorsal region and a cervico-dorsal curve. High dorso-cerv- 



THE DEFORMITIES IN THE LIVING. 



I05 



ical scoliosis has been described by Garre with cervical ribs and may 
be present whether the extra ribs be on one side or on both. 

Schulthess describes a bilateral case. Drehmann, of Breslau, 
has described congenital defects of the bodies of the vertebrae be- 
longing with cervical ribs and has demonstrated the existence of these 
malformations by the X-ray; this may explain why scoliosis is found 
with symmetrical cervical ribs. A diagnosis of congenital scoliosis 
may depend upon a satisfactory radiographical demonstration of 
the deformity. 

Osteogenous. — In rickets one has to depend upon the history for 
the diagnosis; unless it left its mark behind it as a bow-leg, 
knock-knee, or pigeon breast. As a rule, 
cases with marked kyphosis and lordosis 
arouse a suspicion of rickets. Schulthess 
finds that the ordinary antero-posterior 
curve of acute rickets may be associated with 
rotation which may be seen by having the 
child lean forward or by a cross tracing taken 
in that position. Early rhachitic curvature 
always kyphotic, may become kypho-scoli- 
otic, or it may commence as such; later in 
life it remains kyphotic. A lumbar kyphosis 
is regarded by Schulthess as particularly 
suggestive of rickets, with it the back is flat 
with a sharp angle at the promontory. In 
little children with florid rickets Schulthess 
found a few lumbo-dorsal and lumbar curves 
with marked kyphosis becoming double 
curvatures with marked thoracic deformity, 
or with a high dorsal curve or a cervico- 
dorsal curve. The younger rickets begins, 
the more likely is the curve to be low in the 
column. A double curve has, however, been seen in a nursing baby. 
Schulthess and Spitzy, in infants found both thoracic distortion 
and an obliquity of the skull, which is oblique in the opposite direc- 
tion to the thorax, but this deformity may, in some instances, have 




Fig. 52. — Later a' 
curvature from hip dis- 
ease with deformity. 
{Children's Hospital.) 



io6 



ORTHOPEDIC SURGERY. 



begun before the closure of the sutures and have been due to the 
force of gravity only (see chapter VII, page 85). Rhachitic deformi- 
ties of the legs which fail to grow straight, such as bow-leg, knock- 
knee, and coxa vara, may produce pelvic tilting, especially if one 
leg only is deformed. Spitzy holds that in many cases of slight 
lumbar kyphosis in acute rickets a slight lateral curve is present; 
but the diagnosis of rhachitic scoliosis in older people must neces- 
sarily be very difficult if the signs of pre-existing 
rickets have been outgrown. 

Mechanical Scoliosis. — Lateral curvature is 
often the result of a tilted position of the pelvis 
arising from some cause outside of the spine and 
pelvis, a one-sided bow-leg, knock-knee or coxa 
vara, in fact any sort of short leg may cause 
it; shortening from fracture or hi}) disease, 
tumor albus, ankle-joint disease, even flat-foot 
may produce a mechanical scoliosis. I have 
seen it from lengthening of the limb as the re- 
sult of a septic compound fracture of the tibia, 
with suppuration for a year near the lower 
epiphysis of the tibia which apparently stimu- 
lated it to overgrowth. Ankylosis with flexion 
of the hip, knee, or ankle, or congenital dislo- 
cation of the hip may produce it. In the upper 
extremity these mechanical causes are less effec- 
tive, but it may arise from disease of the shoul- 
der-joint with ankylosis. 

Another form of mechanical scoliosis comes 
from empyema. Scoliosis with thoracic de- 
formity as a result of suppurative pleuritis was 
described by Delpech in 1827. In empyema, after the pus is evacuated 
or when absorption takes place, the thoracic space on that side is 
lessened, for cicatrical tissue forms whose slow contraction diminishes 
the pleural capacity both by fastening the diaphragm higher on 
the thoracic wall and by narrowing the intercostal spaces. In most 
cases there is a lateral bowing of the lower part of the dorsal spine 




Fig. 53. — Scoliosis 
from infantile paral- 
ysis, drawing from 
photograph. 



THE DEFORMITIES IN THE LIVING. 



107 



or a double curve with the dorsal convexity toward the sound side. 
The -deformity presents a striking appearance, as the affected half 
of the chest seems much smaller than the healthy side. The worst 
deformity comes in those cases where nature, unaided, cures the empy- 




Fio. 54. — Left empyema — Scoliosis after drainage and resection of ribs. 
(R. W. Lovett.) 



ema by absorption, although lateral curvature may arise frequently 
after surgical treatment, resection of a rib, and drainage. A strong, 
well-developed appearance of the healthy side of the thorax is always 
suggestive. The usual vertebral rotation toward the convexity of 



108 ORTHOPEDIC SURGERY. 

the curve is seen in these cases. A unique specimen in the Warren 
Museum shows rotation of the bodies of the vertebra? toward the 
concavity of the curve in the contracted chest of cured empyema. 
Cases with long continued drainage from small sinuses are especi- 
ally prone to deformity. That non-purulent effusions in the pleural 
cavity may end in lateral curvature seems probable. 

Another form of mechanical scoliosis is seen in paralytics. But 
infantile paralysis of the back often produces no permanent 
deformity, but a malposture, which is unsightly but quite flexible, 
and disappears on lying down. When a bone curvature is present, it 
is the result of a weak leg, a paralyzed arm, or paralysis of one side 
only of the back. The curves are always slight or moderate, — they 
are long bowings, the arcs of a long radius. For diagnosis they usu- 
ally offer no difficult}-. 

Ischias scoliotica is the name of a transitory malposition due to 
myalgia or neuralgia, lumbago, or sciatica. 

Functional Scoliosis. — The diagnosis of functional scoliosis is 
made by excluding other causes. 



CHAPTER VIII. 

LATERAL CURVATURES (CONTINUED). 
METHOD OF EXAMINING AND RECORDING. 

History. — The deformities may be hard to understand and appre- 
ciate correctly, and, as they undergo many changes in the progress 
of the diseas?, it is essential to keep a careful and accurate record 
of the deformity each time it is seen. 

In the beginning the history is to be studied with care and a care- 
ful physical examination is made to discover the causative factors, 
rickets, osteomalacia, empyema, paralysis, etc;, if any are discovered, 
the treatment must include the underlying condition. The eyes 
and ears should be tested, for inequality in the position of the head 
from faulty vision or hearing may be a cause of lateral curvature. 

Physical examination should begin with a view of the bare back 
in the standing attitude. 

The Back in Standing Attitude. — The child's entire trunk and 
in older girls the entire back should be seen, so the patient wears 
a short dressing sack, which is made to open in the back and the 
clothing is fastened about the hips with a belt low enough for half 
the fold between the buttocks to be visible; the feet should be 
placed parallel, about 6 inches apart, and the patient stands with the 
knees straight. You observe from behind the position of the head, 
the outline of the sides of the neck and shoulders, the outlines of 
the waist and the inner borders of the arm, the surface of the differ- 
ent parts of the back and the prominence or flattening of each hip. 
The patient should maintain the position a few minutes until, under 
the effect of fatigue, she sags or slouches. Stooping of the neck 
and shoulders and sticking out the stomach should be noted. Also 
lateral deviation of the trunk from a plumb line held at crease 
between the buttocks; the eye then tries to follow the line of the 

109 



no 



ORTHOPEDIC SURGERY 



spinous processes, which may be facilitated by applying two fingers 
on either side of the seventh cervical and with firm pressure drawing 
them downward keeping the spinous processes between them; in 
a minute a red line appears where the pressure was made; or, 
each spine may be felt and marked separately with a skin pencil. 
Measurement of the greatest distance the spinous processes have 
deviated laterally is made by stretching a string tightly from the 
top of the internatal fold to the tip of the seventh cervical spine 
and measuring from this as a base line. 

The Back in Forward Bending. — After recording his observations, 

the observer, seated behind the 
patient, directs her to bend for- 
ward, and sighting along the back, 
looks for rotation, that is a differ- 
ence in the prominence of the soft 
parts on either side of the spine in 
the lumbar and dorsal regions. 
Then the patient stands erect 
while the observer looks down 
upon the back from above to see 
if the shoulders lie squarely in the 
transverse plane of the body or 
have rotated one in front and the 
other back of the plane. 

Tracings and Photographs. — 
Many devices have been employed 
to make a tracing or record of the 
amount of lateral deviation in different parts of the spine and of the 
amount of rotation, so that the condition may be compared with it. 

One of the simplest was devised by Freiberg, of Cincinnati; it 
consists in holding up against the marked back a long narrow strip 
of glass longitudinally bisected by a straight line which is placed 
so that it connects the fold between the nates with the seventh cervical 
spine; with a pencil for marking glass, dots are then made on the 
glass to correspond with those over the spines; from the glass plate, 
a tracing is then made on paper, or the distance of each dot from 




Fig. 55. — Patient stooping for- 
ward to show rotation in the dorsal 
region in a left dorsal curve. 



LATERAL CURVATURES. 



the line is measured and transferred to coordinate paper and a 
curve of reduced proportions preserved in the record. A good 
photograph of the back, properly lighted, is a very satisfactory 
record, and with a little care may easily be obtained in the office by 
the physician. A thread screen, a square frame strung with strings 
an inch apart crossing at right angles, may be interposed close to 
the patient's back while the photo- 
graph is taken, so that measure- 
ments of the dots over each spine 
may be made on the photograph in 
fractions of an inch. This method 
was employed 15 years ago at the 
Children's Hospital, but was aban- 
doned. It is now in vogue in many 
European clinics. 

Many mechanical devices have 
been constructed to make record 
tracings. Those of Zander and 
Schulthess are accurate but expen- 
sive. 

Flexibility. — The examination 
should include a test of the flexi- 
bility of the spine. 

Forward and backward bending 
is easily observed with the patient 
standing and bending; the hips 
•should be steadied to get out the 
full range of spinal movement. 
Then the patient is asked to bend 
as far as she can to the right and left. When twisting to right and 
left is tested, the surgeon should again hold the pelvis to prevent a 
general twist of the whole body. 

The patient then lies prone in order to discover if the rotation of 
the ribs disappears; if it remains the curve is a fixed one. The 
patient, standing, should then exert her powers to correct her deform- 
ity in order to see which of the three clinical grades she belongs in; 







Fig. 56. — Patient with right dorsal 
left lumbo-dorsal curve stooping far 
down and forward to show rotation, 
a prominence of the lumbar muscles 
and of ribs on the right. 



112 ORTHOPEDIC SURGERY. 

that is, whether she can correct the curve herself, whether she can 
only improve it, or whether she cannot do even that. 

In testing the range of the different spinal movements, it is neces- 
sary for the student to know 
what their range is normally 
in the different regions of the 
spine. 

MOVEMENTS OF THE SPINE. 

Movements of the spine are 
flexion or bending forward, 
hvperextension or bending 
backward, lateral flexion or 
side bending, and rotation or 
twisting. The two last always 
come together, as Lovett and 
D wight have shown, and this 
is equally true of any rod 
which, having already a curve 
in one plane, is bent in an- 
other. It is also true that one 
movement predominates and 
the other is slight. 

Flexion is the most evenly 
distributed of the movements, 
but the thoracic spine bends 
least; the bent back is curved 
like the arc of a large circle. 
Fig. 57.— Left lumbar scoliosis. The Hyperextension takes place 
lines are drawn vertically to the fold be- largely in the lumbar and two 
tween nates in the upright position and , J . . , . . . 

in right and left landing, and they show lowest dorsal vertebrae, in the 
that she bends to the left easily, but is nec k the head makes it hard to 
verv stiff bending to the right. (Lovett.) . . A ,. . . , 

estimate, but there is consid- 
erable motion while the dorsal spine only straightens. Side bending 
in the position of lying on the face or back is a distributed motion 
but is greatest in the dorsal and upper lumbar region; if the child 




LATERAL CURVATURES. 113 

stands leaning forward, side bend occurs only in the middle and 
upper dorsal and the cervical region, the lower dorsal and lumbar 
remain rigid and straight; the erect spine bends sideways chiefly in 
the lower dorsal, the upper lumbar and the neck while the upper 
dorsal spine remains stiff; the hyperextended spine bends to the 
side very little and only at the lumbo-dorsal junction. Rotation, 
freest in the upright attitude, is restricted to the cervical and upper 
dorsal spine in leaning forward and to the lumbo-dorsal junction 
in hyperextension. 

The cervical spine, excluding the atlas, flexes enough to lose its 
lordosis, and hyperextends considerably; side bending and twisting 
are permitted moderately throughout, so their sum is considerable. 

The dorsal spine flexes but little and hyperextends hardly enough 
to straighten, except that the last two vertebrae move more; lateral 
bending is evenly distributed and of fair amount, but the lower spine 
may be locked against it by bending forward and all but the lowest 
part by bending backward; rotation is greatest in the dorsal region, 
about 55 to either side; it takes place most at the top, becoming 
progressively less lower. 

The lumbar spine flexes freely but fails to lose its lordosis com- 
pletely, it hyperextends more than any other region; side bending is 
more than in the dorsal region and is associated with rotation of the 
bodies to the concavity; flexing prevents and hyperextension dimin- 
ishes side bending; very little rotation takes place in the lumbar spine 
and only in the upright position, and may be increased by traction. 

TREATMENT. 

MALPOSTURES AND EARLY SLIGHT DEFORMITIES. 

Slight amounts of spinal deviation are best recognized by holding a 
string as a plumb line with the lower end falling on the cleft of the 
buttocks. In the erect position of a normal spine, every spinous 
process should lie under this plumb line. Slight degrees of curva- 
ture detected in this way should then be examined for rotation by 
bending forward and, if absent, they are classed as postural cases. 

The most common type of malposture is the total left curve, but 



114 ORTHOPEDIC SURGERY. 

it is always accompanied by a slight rotation with a prominence 
of the back in the concavity instead of convexity of the curve the 
reverse of the usual rotation; the spine has a gradual sweep to the 
left, the left shoulder is high, and the right, the depressed shoulder, 
lies on a plane posterior to its fellow. Lumbo-dorsal and dorsal 
curves are also found in the early cases of slight deformity with- 
out rotation. As there is no rotation, it is assumed that there is no 
bony deformity and the condition is a faulty attitude, not a bony 
deformity. The prognosis for complete recovery is good. 

The object of treatment is to substitute correct standing for faulty. 
It is important first to restore to the column its former flexibility, 
often very deficient, and then to strengthen and develop the muscles 
by gymnastic exercises which amount to the setting up drill of the 
soldier. The surgeon should instruct some good teacher of gym- 
nastics how to carry the exercises out. If children are in obviously 
poor muscular condition or overworked at school, they should 
give up school for a year and be placed under the most favorable 
conditions obtainable; errors of vision should be corrected; a short 
leg, if present, should be compensated for; the weight of the clothing 
should no longer be carried on the tips of the shoulders where it 
usually is; exercises should not be pushed beyond the limit of fa- 
tigue, but they should be performed daily, for three-quarters of an 
hour or an hour, for several months, after which gymnastics should 
be done night and morning at home, for at least a year. Half-way 
measures fail. Exercises under the supervision of careless parents 
are most unsatisfactory. 

The following exercises from Lovett's recent book on " Lateral 
Curvature and Round Shoulders," are given with his permission. 
They are not all intended for postural cases; as the careful reader 
will observe, the muscles employed in each exercise are defined, as 
well as the objects which may be realized in the particular sort of 
deformity present. 

Gymnastic exercises may be given in apparatus, or without it; 
the apparatus of Zander, and the apparatus of Schulthess and its 
modifications are in use in many places in Europe, but as such appa- 
ratus is seldom found in this country we pass to the exercises with- 



LATERAL CURVATURES. 



115 



out apparatus. Gymnastic treatment indeed has its limitations, 
and the chief one is that force is not used locally, but that forces 
and movements are distributed over the greater part of the back 
and trunk. 

"Fixation oj Pelvis. — It is essential that the pelvis should be fixed 
during such exercises, as other- 
wise the pelvis is displaced and 
the movement becomes a gen- 
eral and not a local one. A 
simple wooden apparatus may 
be constructed which holds 
the pelvis and does away with 
the necessity of holding the 
hips of the patient between 
the knees which must other- 
wise be done. This saves 
labor on the part of the per- 
son giving the exercises, and 
permits a closer supervision of 
the back than is possible when 
part of the attention must be 
fixed on holding the patient 
firmly. 

" An apparatus, which was 
suggested by that of Bade 
consists of a wooden clamp 
made by two flat boards slid- 
ing at right angles to a hori- 
zontal board (on which they slide) to hold the sides of a pelvis 
of any width. The whole apparatus moves up and down on an up- 
right fastened to a large round floor platform and may be inclined 
at any angle to the horizontal plane. The patient is secured in place 
by sliding in and fastening the lateral clamps at the sides of the pel- 
vis, and by securing the front of the pelvis by a broad leather strap 
passing from one arm to the other. The floor platform is so large 
that the apparatus cannot upset. 




Fig. 58. — Apparatus for fixing the 
pelvis during gymnastic exercises. (R. 
W. Lovett.) 



Il6 ORTHOPEDIC SURGERY. 

"General Routine and Precautions. — It is desirable that the back 
should be exposed during the exercises in order to note the effect of 
each one. For this purpose the patient should wear during exer- 
cises a loose cotton dressing jacket, fastened around the neck and 
opening in the back. This protects the front of the body but per- 
mits inspection of the spine. 

"Such exercises should be simple and corrective in the strict sense; 
that is to say, an exercise which is of use should be seen to straighten 
the spine visibly. Complicated exercises are dangerous and unsur- 
gical. Work to obtain results must be given by a competent gym- 
nast for a period of from one to three hours a day, according to the 
vigor of the patient, and must be continued under personal super- 
vision for a period of some weeks or months to obtain satisfactory 
results. After this, exercises at home can be substituted for part of 
the personal work. 

" As a preliminary of gymnastic work the heart of the patient should 
have been, of course, examined, and the weight should be taken each 
week. Persistent loss of weight is an indication for moderating or 
discontinuing temporarily the exercises, providing that the patient is 
not being overworked at school, in which case the school conditions 
should first be remedied. During menstruation gymnastic exer- 
cises should be suspended. Persistent fatigue, anemia, loss of appe- 
tite, nervousness and frequent or profuse menstruation should cause 
a careful investigation of the patient's environment, as they may arise 
from excess of gymnastic work. 

"The following list of gymnastic exercises, selected from a large 
number, may be regarded as representative of the kind of gymnastics 
likely to be of use within the limits mentioned above. They will 
first be described individually and analyzed, and their application 
to different conditions will be indicated. 

''The selection of exercises must depend on the requirements of 
each case, and so far as possible the especial value of each exercise 
has been indicated. Simple developmental exercises have not been 
included here, as a description of them can be found in books on 
gymnastics. 

'.' In the explanations to be given in connection with each exercise 



LATERAL CURVATURES. 117 

the general mechanical features will be discussed, but it must be 
remembered that conditions observed in the normal do not necessar- 
ily hold true in the deformed spine of scoliosis, although they form 
the best basis for analysis. The more nearly a spine approaches 
the normal the more likely is such analysis to be correct. 

"SYMMETRIC EXERCISES. 

"EXERCISES IN THE STANDING POSITION. 

" In all exercises given in this position the pelvis should be fixed 
unless otherwise stated. It must be remembered that exercises in 
this position call into play in varying relations all muscles concerned 
in maintaining the upright position and, therefore, cannot be as highly 
specialized as can exercises given in the lying position. It must also 
be remembered that the superincumbent weight rests on the laterally 
curved spine, and that the curves are, therefore, not in as favorable a 
condition in such exercises as in the lying position. On the other 
hand they are useful because any improvement of scoliosis must be 
interpreted as meaning improvement in the upright position, and all 
muscles concerned in that are therefore of importance. 

" Fundamental Standing Position. — The patient stands with the 
knees extended, the hands on the hips, the back straight, the head 
erect, and the scapulae brought close to each other. The patient 
should not exaggerate the lumbar curve, and should press down 
with both hands on the hips. 

"I. Shoulder Raising and Sinking. — (i) From the fundamental 
standing position the patient stretches the whole spine upward. The 
surgeon holds his hand slightly above the patient's head and urges 
her to stretch until she can touch his hand with her head, keeping 
both heels on the ground. The position of the hand is made higher 
as necessary. (2) From the upward stretched position the patient 
relaxes to the fundamental standing position. In count (1) the 
patient breathes in and in count (2) breathes out. 

" This is a general exercise calling upon the muscles which main- 
tain the proper erect position, notably the spinal extensors. The 
elevation of the shoulders elevates and fixes the shoulder-girdle, 



n8 



ORTHOPEDIC SURGERY. 



giving a fixed point for the pull of the inspiratory muscles, thus tend- 
ing to increase chest capacity (and a general stretching of the spine 
is also made easier by the fixed shoulder-girdle). The exercise is 
applicable to any case of scoliosis, especially to postural curves, as 
a general mobilizing and corrective one. 

"II. Trunk Bending Forward with Shoulders Raised. — (i) The 
shoulders are raised as in Exercise I, (2) The patient bends her 
trunk forward to the horizontal position, the spine being held straight 
and the shoulders raised, movement occurring only in the hip- 
joints. (3) The patient raises the trunk to the upright position 





Fig. 59. — Exercise I. 
Shoulder-raising. (Lo- 
vett.) 



Fig. 60. — Exercise II. 
(Lovett.) 



with the shoulders still raised and the spine straight. (4) The 
patient relaxes to the fundamental standing position. 

" This combines the essentials of Exercise I with the weight of the 
trunk thrown on the extensor muscles of the back and on the glutei, 
which must be held contracted to maintain the forward bent posi- 
tion and which must contract to bring the trunk again into the 
upright position. It has the corrective effect of Exercise I, in addi- 
tion to which it is a fairly strong extensor spinal exercise with the 
lumbar curve flattened. It is a general mobilizing and corrective 
exercise which may be safely used in cases with a tendency to exag- 



LATERAL CURVATURES. 



II 9 



geration of the lumbar curve. The patient inspires in (1), holds 
the breath during (2) and (3), and breathes out in count (4). 

" The above exercises may be modified and made slightly heavier 
by having the patient place both hands behind the neck with the 
elbows square back as far as possible. This raises the center of 
gravity of the trunk and therefore increases the leverage against 
the muscles. 

"III. Trunk Circling. — Position: Hands on the hips, the trunk 
flexed to the horizontal, the spine straight. From this position the 
patient describes a circle with the trunk about a vertical axis pass- 
ing between the feet. The horizontal plane of the circle described 
is quite irregular, and the movement ._ x 

is divided into four counts. (1) From 
the position of forward bending the 
trunk passes to the right or left through 
side bending with flexion and rotation 
to extreme side bending. (2) From 
extreme side bending the circle is con- 
tinued backward through side bending 
with its accompanying rotation to ex- 
treme hyperextension of the median 
plane. (3) The reverse of count (2). 
(4) The forward bent position is as 

sumed. The face is directed forward 

j • ,1 . Fig. 61. — Exercise III. (Lovelt.) 

during the entire exercise. ' 

"This is a general mobilizing and strengthening exercise. When 
a marked lumbar curve is present the exercise is preferably made 
unilateral to the side that improves rather than increases the lumbar 
curve, e.g., in a left lumbar curve, half circling to the left is prefer- 
able to the complete circle so far as any corrective aspect is concerned. 

"IV. Swimming. — Position: The patient bends forward until 
the trunk is horizontal, the arms are held at the side, the elbows 
flexed, and the hands together against the chest. (1) The arms are 
extended upward beside the head. (2) The arms describe a half 
circle outward and are brought to the sides of the body. (3) The 
arms return to position. 




120 ORTHOPEDIC SURGERY. 

" In this exercise the pelvis is flexed on the hip-joints, and the weight 
of the trunk is thrown forward. The extensor muscles of the spine 
and the glutei are called upon to maintain the position during the 
movements of the arms. All the muscles of the shoulder-girdle, 
especially those concerned in drawing the scapulae together, take 

part in the movement. This 
is a general strengthening ex- 
ercise, especially addressed to 
spinal extensors, and is also 
valuable in cases of flexible 
round shoulders. 

"V. Head Movements jrom 
the Fundamental Standing Po- 
sition. — The head and cervical 
spine, as far as possible, alone 
should participate in these ex- 
ercises. (A, i) Head flexion, 
(2) original position; (B, 1) 
head hyperextension, (2) orig- 




Fig. 62. — Exercise IV. (Lovctt.) 



inal position; (C, 1) side bending of the head to the right or left, 
(2) original position; (Z>, 1) head twisting, right or left, (2) original 
position; (E) head circling with the face to the front, a combination 
of A, B, and C following one another. 

" General mobilizing exercises for the cervical region. For correc- 
tive effect in a cervical curve they should be given only to the side 
that improves the curve. 

''exercises given in the horizontal position. 



"In this group of exercises one set of muscles may be more read- 
ily picked out for exercises than in the erect position. The spine 
when prone is less curved than in the upright position, and is 
slacker and more easily capable of side displacement. The fact 
that symmetric hyperextensions are so much used for their correc- 
tive effect is explained by their empirical value and by anatomic 



LATERAL CURVATURES. 



121 



"Lying on the Face. — VI. Trunk Raising. — Position: The 
patient lies face downward on a table with the spine straight, the 
hands on the hips, the scapulae approximated to each other, the toes 
brought over the end of the table, and the legs secured to the table 
by a strap passing around the table and legs just above the ankles, 
or the legs may be held by the hands of an assistant. (I) The patient 
inspires and raises the trunk from the table, hyperextending the spine 
as far as possible, keeping the head back and the face up, with the 
elbows still held well back. (2) The patient breathes out and sinks 
to the original position. 

" This is a movement of the spine from its normal position to extreme 
hyperextension in which the spinal motion occurs largely below the 




Fig. 63. — Exercise VI. Trunk raising. {Lovett.) 



tenth dorsal vertebra, where hyperextension anatomically takes 
place. The weight of the trunk is raised by action of the back exten- 
sor muscles, which are pretty generally called into play. It is a 
general strengthening exercise for these muscles, but in cases with 
marked increase of the lumbar curve it must not be used to increase 
this, in such cases Exercise II being available. The latter is prob- 
ably a weaker exercise, because in it the extensor muscles do not 
contract to their fullest extent. The exercise may be made harder 
by placing the hands behind the neck and squaring the elbows back, 
which raises the center of gravity. 



r 



122 



ORTHOPEDIC SURGERY. 



<?> 



" The above may be modified in the following manner: The patient 
clasps his hands behind his back above the level of the waist-line, 
with elbows flexed and hands close against the back, and, as he 
hyperextends his trunk, stretches his arms backward forcibly, extend- 
ing the elbows, and keeping the hands clasped. By this modifica- 
tion the scapulae and the shoulder-joints are carried back and the 
hyperextension done with an improved position of the shoulders. 
This is particularly suited to round shoulders. 

"Exercises Lying on the Face, the Trunk Projecting over the 
End of the Table.— The legs rest on the table, the surgeon making 

the ankles secure by means of a 
strap or by holding them. The 
body above the hip-joints hangs 
over the table end, head down- 
ward. The hands are placed 
behind the neck with the elbows 
squared back. 

"VII. Trunk Raising jrom 
Head Downward Position. — (i) 
The patient inspires, and raises 
the trunk as far as possible by 
hyperextending the hip- joints and 
the spine. (2) During expiration 
she sinks to the primary position. 
The spine should be kept in the 
mid-plane and the head not allowed to flex. 

"This is a spinal extension movement mostly without superin- 
cumbent weight, beginning at forward flexion and ending in marked 
hyperextension, calling the extensor muscles into activity from a 
stretched to a completely contracted condition. It thus combines 
the range of motion in Exercise II with that of Exercise VI. It 
is a heavier exercise than either. From the start of the exercise 
till the active horizontal position is reached the spinal extensors 
and glutei are the muscles chiefly active, as the maintenance of bal- 
ance does not require the contraction of other trunk muscles. The 
exercise may be made easier by placing the hands on the hips. It 




Fig. 64. — Exercise VII. Trunk- 
raising from head down position. 
(Lovett.) 



LATERAL CURVATURES. 



123 



is of use as a general strengthening exercise for the back muscles 
in any case where the patient is strong enough to take it. 

"VIII. Trunk Circling. — The position is the same as in Exercise 
VII. The exercise is done in four counts, as described under Exer- 
cise II. 

" This is a heavier exercise than II because the weight of the trunk 
is a factor entering into each component of the movement. For 
corrective effect it should be given only to the side that improves 
the lateral curve. 




Fig. 65. — Exercise VIII. Trunk circling. (Lovett.) 

Exercises lying on the back: the chief one of these is the familiar 
trunk-raising from the lying position. This is not an exercise 
for back muscles but for abdominal muscles, which are often weak, 
in cases where a correction of lordosis is demanded. 



'EXERCISES IN THE SUSPENDED POSITION. 

" The patient stands erect, and the head is pulled vertically upward 
by means of a Sayre head-sling, which embraces the chin and occi- 
put. Traction should be made by a compound pulley, and the 
patient or the surgeon may hold the rope. Suspension is mildest 

(1) when the feet are not made to leave the floor; next in grade comes 

(2) the position of tiptoe induced by the traction, and (3) a greater 



I2 4 



ORTHOPEDIC SURGERY. 



pull is secured by lifting the whole body until the feet swing free. 
In this case the traction force equals the body-weight. The maxi- 
mum traction can be secured (4) by strapping the thighs down to 
a seat on which the patient sits. An upward pull greater than the 
body-weight can now be exerted on the head. 

"Head suspension is a passive stretching of the spine, corrective 
through its entire length, tending to improve both rotation and side 
deviation at the curves, but exercising still more force upon the 
more nearly normal parts of the spine because the latter are more 




Fig. 66. — Swimming over end of table. (Lovett.) 

movable. Suspension by the arms is less efficient, and does not 
affect the cervical vertebrae as does head suspension. Hanging 
is a generally useful and purely mobilizing procedure suitable to any 
case, slight or severe. 

"If it is desired to make hanging exercises more locally corrective 
in the dorsal region the patient should hang by the hands from, a bar, 
the hand on the convex side of the lateral curve grasping a loop on 
the bar which is at least two inches below it. By this means the 
concave side will be subjected to a greater stretching. 

"miscellaneous symmetric exercises. 

"IX. Weight Carrying on the Head. — A bag filled loosely with 
sand, weighing from 3 to 15 pounds, is placed on top of the patient's 



LATERAL CURVATURES. 



125 



head, and she walks slowly to and fro with the arms preferably 
clasped behind the neck and the elbows squared back. The exer- 
cise may be made more difficult by having the patient walk on tip- 
toe. The attitude assumed should be as erect as possible and the 
weight as heavy as can be carried steadily. 

"It is a matter of common information that the habitual carrying 
of baskets and loads upon the head induces an erect carriage and a 
straight spine. The presence of weight upon the head necessit- 
ates getting the spine as much as possible straight under the weight, 
as it is thus most economically carried, and this instinctive adjust- 
ment to superincumbent weight is depended on 
for its corrective effect. To carry a weight on the 
head with the spine not held in its best position 
by muscular effort would be undesirable. The 
exercise is suited to mild cases with noticeable bad 
carriage and poor balance. 

" X. Mirror Selj-corrective Exercise. — The pa- 
tient, bared to the hips, faces a mirror in front of 
which hangs a plumb-line. The patient then 
stands in such a position that the plumb-line cuts 
the middle of the pelvis, and by a muscular effort 
brings the middle of the thorax and the vertical 
line of the face as nearly as possible under the 
plumb-line, bringing thus three important land- 
marks into the median line of the body, thus secur- 
ing an improved position. This is held for a few 
seconds and then the relaxed position resumed. The exercise is 
repeated several times, the improved position being held longer each 
time. 

"The exercise is a muscle training and is not in any way a mobiliz- 
ing exercise, but enables the patient to associate a certain position 
with a certain muscular effort, and is of great value in enabling 
patients to identify by muscular sense the corrected position. The 
exercise requires but little effort and may be done at home without 
assistance. It may be modified in various ways by adding free-arm, 
staff, or dumb-bell exercises, which change the center of gravity, 




Fio. 67.— Trunk- 
twisting. {Lovett.) 



126 ORTHOPEDIC SURGERY. 

strengthen muscles approximating the scapulae, and prolong the 
corrected attitude. 

ASYMMETRIC EXERCISES. 

"XL Hip Sinking (Hoffa). — Position: Erom the fundamen- 
tal standing position the patient advances the foot, on the side oppo- 
site to the convexity of the lateral curve, forward and outward about 
two foot-lengths, (i) The patient bends the forward knee, sink- 
ing the hip on that side. (2) The patient resumes the primary 
position. 

"A passive side correction of the lumbar curve, due to a lowering 
of the pelvis on the side of the advanced leg when the knee is bent. 
Suitable for lumbar curves. 

"XII. Self-correction (Lorenz). — The patient assumes the funda- 
mental standing position and places the hand of the side to which 
the dorsal spine is convex upon the side of the thorax opposite to 
the greatest dorsal curve; the other hand is then placed on the ilium. 
(1) By a side thrust of the hand on the thorax the patient corrects 
or overcorrects the dorsal curve, maintaining the correction for a 
few seconds. (2) The patient relaxes to the primary position. The 
exercise may be modified by placing the hand on the side to which 
the dorsal spine is concave on the top of the head, as it thus tends 
to raise a low shoulder. The rest of the exercise is performed as 
described. 

" A side thrust of the dorsal spine with pressure applied to the con- 
vexity of the dorsal curve against resistance furnished by the other 
hand on the ilium or the head. Suitable for dorsal scoliosis, but 
not powerful, and useful as a means of stretching; chiefly good 
because it can be done by the patient unaided at frequent intervals. 
Exercises XI and XII may be combined for a double curve with 
one element dorsal and the other lumbar. 

"XIII. Hip Sinking from Stool. — Position: The patient stands 
erect on a stool on one foot (the foot on the side of the convexity 
of the curve). (1) The patient lets the free leg sink as much as 
possible, thus lowering the pelvis and hip on that side. The knee 



LATERAL CURVATURES. " 127 

of the supporting leg must be kept straight. (2) The patient resumes 
the original position. 

" A passive side stretching of the lumbar curve suitable for lumbar 
scoliosis. The leg and pelvis drag down on the side of the con- 
cavity of the lateral curve, tending to stretch contracted structures 
and straighten the curve. 

"XIV. Trunk Hyper extension with Side Bending — Lying on the 
Face. — The patient lies face downward on a table or on the floor 
as described in Exercise VI. (1) The trunk is raised from the table 
as far as possible by hyperextending the spine. (2) From this posi- 
tion the trunk is bent to the side toward which the lumbar curve is 
convex. (3) Position 1 is resumed. (4) The prone lying position 
is resumed. 

"This exercise is an active lateral flexion of the spine in the posi- 
tion of hyperextension. As hyperextension locks the dorsal region 
against side flexion, the movement is almost wholly confined to the 
lumbar region. If there is a right dorsal curve in connection with 
a left lumbar curve, bending to the left, while it corrects the lumbar 
curve, does not at the snme time greatly increase the dorsal curve, 
as that part of the spine is locked against side bending. The exer- 
cise is, therefore, suited not only to lumbar curves but especially to 
compound curves in both dorsal and lumbar regions. 

"XV. Drawing up the Hip — Lying on the Face. — Position: 
The patient lies prone on a table, holding the end with both hands, 
the arms extended and the spine and legs in a straight line. (1) The 
surgeon grasps the ankle on the side of the lumbar convexity and 
resists while the patient draws the hip up as far as she is able, the 
knee being kept straight. (2) Position 1 is resumed. 

"The approximation of the side of the pelvis and the thorax on 
the side to which the lumbar curve is convex is brought about by an 
active contraction of the muscles on the convex side of the lumbar 
curve which it is desirable to develop. The amount of work thrown 
on these is determined by the amount of traction made on the ankle. 
The exercise is suited to cases of lumbar curves or to the lumbar 
element of compound dorsal and lumbar curves. 

"XVl.Selj-correclion with Arms Extended Behind Back (Mick- 



128 ORTHOPEDIC SURGERY. 

ulicz). — The patient stands without pelvic fixation with the arms 
hanging behind the back, with extended elbows, and the hands 
clasped loosely with the palms together, (i) The patient bends 
forward, flexing the spine. (2) The patient then straightens the 
arms with force, getting the shoulders as far back as possible and 
stretching the hands down, and then describes a half circle to the 
right or left to the hyperextended median position. The bend is 
to the right in right curves and vice versa. 

"The exercise is a side flexion made in the direction that improves 
the lateral curve, made with the shoulders in a corrected position. 
The arm on the convex side presses against the rotated thorax and 
has some corrective effect. The exercise is particularly useful in 
dorsal scoliosis with increase of the dorsal physiologic curve (kypho- 
scoliosis). 

" XVII. Partial Suspension by One Arm with Other Arm and 
Leg Locked. — Position: The patient standing by a ladder or under 
a bar, that can be reached without rising on the toes, grasps one 
rung of the ladder or the bar with the hand of the side to which the 
spine is concave. On the opposite side, the convex, the arm passes 
under the knee, the thigh being flexed at the hip, and the shoulder 
and pelvis are thus approximated. (1) The patient thus standing 
on one leg flexes that knee and allows the body-weight to come upon 
the arm. (2) The original position is resumed. 

"When the arm is placed under the knee the pelvis and shoulder 
are approximated on that side and the spine made convex to the 
other side as far as it will go. The structures on the concave side 
are thus put on the stretch and by allowing the body-weight to come 
on the arm holding to the ladder, a further stretching force is exerted 
on the structures on the concave side. The exercise is suited to 
total and dorsal curves. 

" CREEPING EXERCISES (KLAPP). 

"In these exercises the patient supports the trunk in a horizontal 
position with the hands and knees or feet on the floor. The hands, 
knees, and toes should be protected by leather pads which are strap- 
ped on. 



LATERAL CURVATURES. 



12g 



"XVIII. Symmetric Creeping. —The hand and knee of the left 
side are placed close together, with the knee inside of the hand, 
the head is twisted with the face to the left, and the trunk is rotated 




Fig. 68. — Creeping exercise of Klapp. (Lovett.) 

with the right shoulder upward. The right arm is extended beyond 
the head and the hand placed on the floor, palm down and fingers 
forward, as far forward as possible and directly in front of the left 
knee. The right knee is placed as far back and as near the median 




Fig. 69. — Creeping exercise of Klapp. (Lovett.) 



line as possible; the spine is strongly flexed to the left. The creeping 
consists of forward locomotion by a series of reversals and regainings 
of the position described. The mechanism of the first reversal is 
9 



13© 



ORTHOPEDIC SURGERY. 



as follows: The right knee is drawn forward to the inner side of the 
right hand in its original place and position, the left arm is extended 
above the head, and the hand placed as far in front of the right knee 
as possible with the palm down and fingers front. At the same 




Fig. 70. — Creeping exercise: holding the position. (Lovett.) 

time the spine is rotated to bring the left shoulder high, the face is 
twisted to the right, and the spine flexed to the right. The restora- 
tion to the first position is secured by again moving the back knee 
(left) and the back hand (right). 




Fig. 71. — Sideways creeping. (Lovett.) 



" This is a general muscle-strengthening and spine-mobilizing exer- 
cise. It is comparatively mild and may be continued for long periods 
of from twenty to forty minutes. It is said to be of value to lengthen 
shortened muscles and ligaments on the concave side. Symmetric 



LATERAL CURVATURES. 



131 



creeping is properly that which is done rapidly, and is of most value 
in restoration of flexibility. 

"A modification is made by creeping slowly, holding each posi- 
tion and putting force into the stretching, usually holding the posi- 
tion longest which stretches the concavity of the most marked curve. 
Another modification is creeping in place, which differs from the 
above in that the patient does not attempt locomotion. The posi- 
tion is somewhat as above except that the fingers of both hands are 
placed on the floor, pointing opposite to the side to which the face 
looks. The trunk is rotated till the side with the forward arm is 
uppermost, and the arm is carried directly over the head while the 
under arm is flexed at the elbow which points to the side toward 
which the face is turned; the posterior knee is straightened, and 
the part only of that limb touches the floor. The patient then endeav- 
ors to look upward beneath the forward reaching arm. This is 
best employed as an asymmetric exercise to correct the dorsal con- 
vexity and stretch the side of the concavity. 

"XIX. Creeping Sidewise. — There is a third asymmetric varia- 
tion in 'creeping sidewise' toward the side showing the concavity 
of the curve to be corrected, for example, in a left total curve. The 
patient creeps sidewise to the right. The left hand and knee are 
placed under the trunk, and as far as possible to the right of the 
right hand and knee. The right hand and knee are then advanced 
to the right and the above is repeated. The face should look to the 
left. 

"This is a corrective exercise similar to other forms of creeping, 
and may also be used for dorsal curves as well as for those of the 
total type." 



CHAPTER IX. 

LATERAL CURVATURES (CONTINUED). 

STRUCTURAL OR TRUE SCOLIOSIS. 

Structural lateral curvature is less encouraging to treat. The 
spine is stiff, the vertebrae distorted, the force of gravity is constantly 
increasing the deformity during the daytime. The results are 
often not satisfactory; yet in young children with moderate degrees 
of deformity complete cures are possible; in older children, great 
improvement in the standing attitude> and in adolescents and adults, 
considerable improvement in symmetry of form and general car- 
riage may be expected and obtained. 

Treatment must be long continued and demands, on the part of 
the patient and surgeon, a good deal of time and attention, and 
necessitates a combination of gymnastics, with the use of machines 
designed to correct the malposture and the use of corrective jackets. 
For the severest forms of adult curves, operations have been bene- 
ficial in the hands of Hoke. 

Measures to Regain Flexibility. — Treatment must first aim to 
loosen up the spine so as to make an improved position possible. 
A careful selection from the list of exercises already given will guide 
the surgeon in attaining this object. Lovett finds it essential that 
the pelvis should be fixed during many of the exercises, — other- 
wise the movements are general and do not aid in obtaining local 
flexibility of the spine. Little may be accomplished by these exer- 
cises in the severest forms of curves, although Klapp, of Bonn, has 
undoubtedly been very successful with the creeping exercises which 
are included in Lovett's list. Daily massage of the trunk at the 
time of exercising is a help. After flexibility is restored, exercises, 
which are simple and at the same time corrective, should be devised 
to suit the case by a well-trained teacher of gymnastics in collabora- 
tion with the surgeon. In order to obtain corrective results, the 

132 



LATERAL CURVATURES. 



133 



work must be given under the eye of a competent gymnast for one 
to three hours a day according to her vigor for many weeks before 
the exercises at home can be substituted. These usually fail and 
unless a gain is noted from lesson to lesson should be superseded by 
forcible correction. 

Passive stretching of the spine may be secured by hanging by 
the arms and by traction on 
the head; this should always 
form a part of the daily gym- 
nastic exercises. Many forms 
of apparatus, like the Beigel- 
Hoffa frame and the kypho- 
tome of Taylor, exert screw 
pressure by pads upon the sides 
of the chest during suspension. 
Lovett believes more may be 
accomplished by side pressure 
when the muscles are relaxed 
by lying down, for even on a 
cadaver the lateral correcting 
force causes a greater spinal 
displacement when the patient 
is in the recumbent position 
than when either horizontal 
or vertical traction is employed. 
In many of these machines both 
traction and screw pressure are 
employed in the recumbent or 
the erect position. 

A simple appliance for stretch- 
ing lateral curvature of the spine 

by side pressure in prone position is the curvature board used at 
the Children's Hospital. The patient lies face downward with 
the knees flexed on a board 3 feet wide by 4 feet long; a canvas 
strap passes around the upper part of the thorax and it is fastened 
to a cleat; a similar one passes around the pelvis and is fastened to 




Fig. 72. — Advanced right dorsal scoli- 
osis in an adult. {Lovett.) 



134 



ORTHOPEDIC SURGERY. 



a cleat on the same side of the board; while a third is placed between 
the other two, so as to pull the point of greatest curvature in the 
opposite direction; the cord from this canvas strap passes through 
a compound pulley, by means of which any reasonable degree of 
force may be exerted. The use of this stretching board is limited 
to correcting lateral deviation — rotary changes are not much influ- 
enced. 




Fig. 73. 



-Lovett's correction board for lateral curvature. 
{Children'' s Hospital.) 



A more effective appliance was devised by Z. B. Adams, of Boston, 
for daily forcible corrections and for the application of corrective 
plaster jackets. 

When a machine is used for stretching, it should be applied for 
as long a time as the patient can comfortably stand it, which is gen- 
erally from 15 to 30 minutes daily. Even very severe cases of struc- 
tural scoliosis have been benefited by this stretching. 

Corrective Plaster Jackets. — The plaster jackets may be applied 
under force. For description of the method of application, the 
reader is referred to Chapter XX, page 339. The object is to stretch 
contracted structures and improve the curvature by the continuous 



LATERAL CURVATURES. 



135 



application of moderate force. Lovett applies them to patients 
lying prone with the legs flexed in order to diminish as much as 
possible the physiological curves in the spine, and thus place it in 
the most favorable condition for the correction of both side devia- 
tion and rotation. He has demonstrated some diminution in the 
extent of the curves within the plaster jacket by means of the X-ray, 
but the improved attitude visible to the naked eye is far greater; 
and some gain from one to two inches in height from the straight- 




Fig. 74. — Apparatus for forcible correction by plaster jackets. {Lovett.) 



Jackets are often worn for a period of from two to three weeks 
and renewed as long as further correction is obtained. They 
may then be made removable and worn except during exercising, 
or a brace may be used until the trunk muscles are sufficiently devel- 
oped to maintain the improved attitude which has been secured. 

Lately a patient returned who had worn one of these corrective 
plaster jackets over a year, because she had been away. She had 
improved greatly both in her attitude, in the amount of rotation 
and the alignment of her spine. Perhaps this is the better way to 
treat many. 



136 ORTHOPEDIC SURGERY. 

As after-treatment a removable brace or a jacket is used 
afterwards and the object should be to maintain the improved 
position. Though considerable temporary gains may be made by the 
corrective method, much remains to be done to make the gain per- 
manent. It is first made possible for the patient to be placed in 
a correct position. Next she must be taught to assume it herself 
for short periods of time, by her own efforts; and lastly, her muscles 
must be so developed that she can maintain the improved position 
constantly. The use of gymnastic exercises 
should be continued, but the aim is no 
longer to secure flexibility, but to make the 
back and trunk strong. Gymnastics for self- 
correction, for exercising the muscles on the 
convex of the curve, gymnastics for back- 
ward bending, gymnastics with heavy weights, 
above all, much work and great patience are 
required, and it is often necessary that some 
form of retentive apparatus be used to main- 
tain the position until the muscles are 
strong enough to do it unaided, and it is here,that a brace comes in. 
For description of the brace for lateral curvature see Chapter XXI, 
page 362. 

A removable plaster-of-Paris or leather jacket made on a corrected 
plaster torso is also useful. It is sometimes desirable to cut this 
jacket into two pieces horizontally, and separating these as much 
as possible, to have the patient stand in the best corrected posi- 
tion, while the surgeon marks upon the jacket the places where the 
flat iron connecting bars should be riveted on in order to make the 
jacket maintain the correct attitude. The brace and jacket may be 
used to correct; but the best correction by jackets and braces has 
been obtained in young growing children with congenital curva- 
tures. In such cases the brace is used for years. u As the twig is 
bent the tree's inclined. " 

Wullstein advanced the knowledge of lateral curvature materi- 
ally when he discovered that he could produce lateral curvature in 
puppies and dogs by keeping their spines bent three months in a 




LATERAL CURVATURES. 



137 



plaster bandage or harness; also when he discovered that strong 
traction applied to the cadaver sitting combined with obliquity and 
rotation of the seat and straightening the shoulders could straighten 
severe structural curves, — a proceeding which he rendered still 
more effective by the pressure of screw-pads against the side of the 
chest. He applied this principle to patients, putting them in for- 
cible-corrective jackets applied sitting with very powerful traction, 
obliquity of the seat, rotation of the seat and shoulder, and pad 
pressure. These jackets are worn two 
or three months and followed by the use 
of a brace. 

Preparatory exercises and five minute 
stretchings in the same apparatus he em- 
ploys daily for six weeks before the ap- 
plication of the first jacket in order to 
gain flexibility and make it possible to 
correct in the jacket. The head, shoul- 
ders, and neck are included in the jacket, 
and windows are cut out to give room 
for the flattened chest to expand on the 
side of concavity posteriorly, and of the 
convexity, anteriorly. These Wullstein 
jackets should be made strong and 
heavy and the pressure pads are left 
inside; they should be worn from two 
to four months as they are not uncom- 
fortable. 

In scoliotics, who are flexible with a fair development of muscle, 
Wullstein applies two corrective jackets, each worn for six weeks, 
after which he substitutes a removable brace, which holds the back 
in the corrected position and allows some motion to it. He has the 
uprights in the lumbar region replaced by strong, spiral, flat, steel 
springs which allow a certain amount of lumbar motion, but in for- 
ward bending, side bending, and twisting, always act to throw the 
patient back into the correct position. A head support is often 
used. 







Fig. 76. — Congenital Sco- 
liosis in brace. {Children s 
Hospital.) 



138 ORTHOPEDIC SURGERY. 

The removable brace is worn three months or more, during which 
time gymnastic exercises and massage are kept up daily. Twice 
a day the spine is forcibly extended and overcorrected in the ma- 
chine. If the spine is not corrected by this time, he recommends 
repeating the procedure, starting with two more plaster jackets, 
to be worn for four to six weeks, followed by the brace, gymnastics 
and massage. 

In very severe stiff scoliotics, whose muscles are much atrophied, 
weak and degenerated, Wullstein found it impossible to accomplish 
any correction in the jacket. 

Operative Treatment. — Tenotomies for scoliosis have been tried 
and abandoned. Operations upon the ribs have as yet found 
little favor, althovgh Hoke, of Atlanta, reported a single case in which, 
by resecting and overlapping some of the most flattened ribs, divid- 
ing others subperiosteal^, fracturing others, and forcing the patient 
into a plaster bed moulded over a much corrected cast, a greatly im- 
proved back was obtained after three operations. 

MALPOSTURES OR POSTURAL LATERAL CURVATURES OF 
THE SPINE. 

These curves have been defined as lateral curvatures without bony 
change. Their importance is very great, for if left untreated they 
lead to true bony deformity and doubtless many malpostures really 
represent the unrecognized early stage of true rotary lateral curva- 
ture with bony deformity. 

The commonest form of lateral curvature among these is the total 
curve to the left often accompanied by rotation in the lower dorsal 
spine, a rotation which reversed, that is to say, one in the oppo- 
site direction to what usually obtains in lateral curvature; there is 
a backward prominence on the side of the concavity of the curve 
and a corresponding flattening on the side of the convexity; this 
is slight and may be seen only in forward bending. Slight short 
lumbo-dorsal and dorsal curvatures have been observed but they 
are always characterized by the fact that the patient can correct 
them herself or can be taught to do so in a comparatively short time, 



-1 



LATERAL CURVATURES. I 39 

and treatment, as we have already seen, is entirely by gymnastics. 
The same precautions should be employed for the support of the 
clothing which is recommended for round shoulders (Page 142). 
Occasionally when a child on account of some constitutional trouble 
fails to get strong under gymnastics, a light brace or support is 
indicated, but this sign is generally that the child needs treatment 
for some constitutional cause of her debility. The general hygiene 
of these children must be looked after; overfatigue at school is to 
be guarded against; it is best sometimes to withdraw the child from 
school for six months or a year in order to allow her bodily strength 
to catch up with her growth, for a large proportion of malpostures 
arise during the rapid growing period of puberty, — a factor often 
overlooked. Faulty attitudes habitually maintained for many hours 
have been considered a cause of scoliosis for many years. The 
violinist frequently developes it, the itinerant harpist, who wanders 
through the streets with his heavy harp slung over one shoulder, 
the hotel porter, and the quarryman who habitually carry heavy 
loads on one shoulder, — all have been known to have deformities 
attributed to these causes. The faulty position of the child sitting 
at school has been regarded as one of the most frequent factors in 
the production of malposture. The way children sprawl at their 
desks as they write is familiar to all. To correct this, special forms 
of desks and chairs have been introduced into many public, private 
schools, which are adjustable both in height and the proximity of 
the desk top to the sitting child. It was hoped that teaching a 
vertical hand-writing instead of a slanting one in the public schools 
would stop this; but figures are lacking, however, to show any dim- 
inution in the frequency of scoliosis in children since these reforms 
were instituted in the schools. 

STOOP SHOULDERS OR ROUND BACK. 

What is usually called round shoulders consists in several deform- 
ities, of which the main types are the round back, the round hollow 
back, and forward shoulders. They are all variations from a type 
which is regarded as normal. The military attitude which has been 



140 



ORTHOPEDIC SURGERY. 



described as normal by Staffel is more nearly normal for the adult 
than the child; while it is a good standing position for all people 
with crooked backs to strive for, it is not the average or normal 
attitude of children. 

Adequate descriptions of these attitudes in the different periods 
of childhood have not been formulated, but they are recognized, in 
a rough way, by all who are familiar with children. 

The round back is the expression of 
muscular weakness. The typical round back 
is seen in the position of a child in the sitting 
posture whose back muscles are paralyzed. 
There is a total kyphosis of the whole column. 
Schulthess observed it among paralytics, 
among young children who have had rickets, 
and in bakers as the result of their occupa- 
tion, and also among rustics who have for 
years been digging the ground. 

The deformity is a lumbo-dorsal kyphosis 
with a slight angle or a very short curve 
above the sacrum; sometimes the apex of 
the backward convex curve is low in the 
dorsal region and sometimes fairly high. 

The deformity is often associated with a 

lateral curvature of the spine. Rarely do we 

see round back when the lumbar spine is 

straight, or even slightly lordotic, but there 

is a common type where the lumbar hollow 

is accentuated as well as the backward curve 

of the thoracic spine, it is called the hollow 

round back. Both of these are associated with forward inclination 

of the head and neck and a moderate forward displacement of the 

shoulders. 

Hollow Round Back. — The child with hollow round back 
sticks his stomach out, stoops his shoulders and may hold the head 
normally. The causes of hollow round backs are muscular weak- 
ness and defects of the eyes or the ears; they may be stiff or flexible, 




Fig. 77. — Round 
back. {Children' s Hos- 
pital.) 



LATERAL CURVATURES. 141 

but are usually stiff if the deformity has been of long standing. There 
may be an accentuation of the dorsal kyphosis with no change in 
the other curves of the spine as is seen among children who are 
bookworms and in old people, but children are more apt to have a 
much increased lordosis with a relatively slight increase in the normal 
dorsal kyphosis. The hollow round back may arise from late 
rickets, or be a late manifestation of rickets in childhood. It is 
also associated with weakness of the muscles and faulty attitudes 
from improper clothing or occupation. 

A total lordosis of the whole column has been described as a rare 
affection by Schulthess, — a single long curve concave backward, 
with the apex at the lumbo-dorsal junction and decreased pelvic 
obliquity. He found it in paralysis of the muscles of the back, and 
in lordo-scoliosis; it has been considered a congenital condition. 
Lordosis is increased whenever it is impossible to completely extend 
the hips. When lumbar lordosis is increased from any cause, round- 
ing of the dorsal physiologic curve takes place to balance the body, 
but there are a few cases of lordosis where the spine rises almost 
vertically afterward. Increased lordosis of the cervical spine with 
the apex at the third or fourth cervical vertebra is found with the 
hypertrophic type of arthritis deformans. Lumbar lordosis may ex- 
tend beyond the lumbar segment and involve the lower thoracic 
column. 

Forward Shoulders. — Forward shoulders, as we have already 
seen may be associated with round back, or may come independently 
as in the accompanying picture. The cause is weakness, often com- 
bined with an improper pull of the clothing on the shoulders. 

The influence of clothing is more often seen in girls than in boys. 
Heavy skirts, petticoats, and stocking supporters are all attached 
to an underwaist, which hangs upon the shoulder-tips. Although 
made in many different styles, underwaists always drag upon 
the outer or movable portion of the shoulders, which, when lowered 
under fatigue, most naturally droop forward in a circular arc, the 
radius of which is the clavicle. The weight of the clothing should 
not hang from the tips of the shoulders but from the base of the 
neck. A simple device is to put boys into suspenders and have 



142 



ORTHOPEDIC SURGERY. 



them crossed in front as well as behind; special waists should be 
made high in the neck, and sleeveless with a short shoulder, so that 
the weight has to be carried on the rigid, immovable portion of the 
shoulder close to the neck. The front should be made loose and easy 
A simple method of recording the amount of antero-lateral cur- 





Fig. 78. — Hollow round 
back, from photograph, j 



Fig. 79. — For- 
ward shoulders, 
drawn from pho- 
tograph. 



vature has been devised by Lovett. The patient stands with the 
right side toward a vertical measuring rod on which slides an L- 
shaped bar which can be raised or lowered to the level of the marked 
points on the child's body. The following points are marked on 
child and their height and distance from a vertical upright is re- 
corded on coordinate paper. 



LATERAL CURVATURES. 



143 



The mastoid process, the seventh cervical spine, the seventh dorsal, 
the fourth lumbar, the middle of the trochanter, the head of the fibula, 
and the external malleolus. The curve so made in healthy subjects 
showed very little variation, except that in girls the fourth lumbar 
was farther forward than in boys. In looking over the curves, four 
distinct forms are noticed: first, where there is general rounding of 
the body; second, where a short round back; third, the back is too 
straight or too hollow; and fourth, where the back is straight but 
the head is run out forward. 
When round shoulders are 
corrected it is the body posi- 
tion which is modified, not 
the spine. 

Treatment. — Treatment 
can almost always be entrusted 
to a competent instructor of 
gymnastics under supervision 
of the physician, but some 
backs are very stiff and do 
not quickly yield to exercises. 
Such may be rapidly improved 
by forcible plaster jackets. 
These may be applied on the 
ordinary hammock frame or 
the special frame devised by 
Lovett for the purpose. The 
shoulders should be included 
and carefully protected with 

felt. The jackets should be worn for three weeks and every few 
days extra felt padding may be put between the jacket and the 
front of the shoulder-tips to still further correct them. After 
forcible correction in a jacket, a light brace should be worn for 
several months to prevent relapse, and gymnastic exercises pre- 
scribed daily. For a light brace which is efficient for this pur- 
pose see Chapter XXI, Fig. 173. This brace is especially effective 
in correcting forward displacement of the shoulders and has been 




Fig. 80. — Plaster jacket applied for 
resistant forward shoulders in a sco- 
liotic. {Children's Hospital.) 



I44 ORTHOPEDIC SURGERY. 

employed for the rapid correction of the stiff deformity instead of 
plaster jacket treatment. 

DEFORMITY OF THE THORAX INDEPENDENT OF 
THE SPINE. 

Funnel Chest.— Funnel Chest, Trichterbrust, Thorax en Enton- 
noir, Pecho en Embudo. This deformity is characterized by a depres- 
sion' of the median anterior chest wall, the shape of the depression 
resembling a funnel or a furrow. It may be acquired or congenital 
and in the latter case has been attributed by Zuckerkandl and Rib- 
berts to the pressure of the chin, for they found that on extreme 
flexion of the head of a baby two days old the chin exactly fitted the 
depression, and Hogmann says that the fetus heels may likewise 
press the sternum in. While many cases are doubtless congenital, 
many are also acquired, for it was observed to arise as late as the 
eighth year. Theories have been advanced without proof, such as 
tardy development and tardy ossification of the sternum, rhachitic 
disease of the fetus, overgrowth of the ribs, etc. 

Treatment.— Hoffa attempted by strong adhesive plaster to 
pull the depressed sternum forward. He also used a suction ap- 
paratus fitting exactly the contour of the breast wall, and by it 
the sunken portion was raised temporarily. Breathing exercises 
are of value. Deep expirations with pressure of hands on the sides 
of the thorax, blowing into the mouth-piece of a trumpet, or into 
a spirometer, are advisable. It would seem that a diminution of 
the chest capacity must lead to a predisposition to diseases of the 
lungs, pleura and heart. Chicken breast is almost always asso- 
ciated with rickets and will be considered in Chapter XVII. 



CHAPTER X. 
DEFORMITIES OF CHILD-GROWTH (CONTINUED). 

COXA VARA, COXA VALGA, BOW-LEGS AND KNOCK- 
KNEES NOT DUE TO RICKETS, FLAT-FOOT, ETC. 

COXA VARA AND COXA VALGA. 

Coxa valga has but lately been recognized as a deformity and 
Coxa vara is still to many a discovery of recent date. They depend 
entirely on abnormalities of the angle of elevation of the neck of 
the femur. The average or normal elevation is 125 for the adult 
and 135 for the child. Variations between 120 and 140 are 
considered normal; smaller angles are called coxa vara, larger coxa 
valga. 

COXA VARA. 

Coxa vara may originate congenitally or come on during child- 
growth without assignable cause, or it may arise from trauma, 
rickets, osteomalacia, or inflammatory bone disease. The congenital 
form, first described by HofTa and Helbing, is characterised by some 
lack of development of the head of the femur. Three boys have it 
to one girl. 

Coxa vara whether congenital, acquired during natural growth 
in childhood, or through rickets, may present the following symp- 
toms: a limp which is slight or moderate, pain in the leg and thigh 
which comes and goes, and getting tired easily. «J3n examination 
there is a little shortening, the trochanter is above the Nelaton-Roser 
line, and motion at the hip is restricted in abduction only. In 
double cases there is a marked decrease in the straddle; and in some 
the adducted hips make him walk as if he had double congenital 
dislocation of the hips or even like a child with spastic paralysis; 
lordosis is often increased in double cases and single ones may have 
10 145 



146 



ORTHOPEDIC SURGERY. 



a lateral curvature; if they toe out flat-foot develops. An aid to 
diagnosis is the test of Trendelenberg; the child stands on the affected 
leg and the observer notes from behind the position of the buttocks, 
with a normal hip they remain level, with coxa vara owing to disuse 
of the abductors of the hip he stands with the hip adducted and in 
so doing lowers the pelvis and buttock on the unsupported side, 

while in congenital dislocation 
of the hip the pelvis sinks on 
the supported side. 

In early childhood or in the 
florid stage of rickets, correc- 
tion may be made by traction 
in bed in an abducted position, 
or by a plaster-of-Paris spica 
bandage applied in the position 
of forced abduction under an- 
aesthesia; a supportive splint 
like the Thomas knee splint or 
the convalescent hip splint 
should be worn a year to pre- 
vent subsequent bending. To 
quiet acute pain rest abed, fol- 
lowed by massage and exer- 
cises are used, the latter also 
serve to increase the range of 
abduction and to strengthen 
the abductors. 

Henle and Mikulicz removed 
the top of the neck and the ad- 
joining part of the head and of the acetabulum in order to restore ab- 
duction. Osteotomies are used for the same object both on the femoral 
neck and on the shaft just below the trochanter minor; strict aseptic 
precautions are to be observed; cuneiform osteotomy offers little 
advantage over linear osteotomy; the same rules and precautions 
are indicated as in osteotomy for ankylosis of the hip in malposition. 
The limb strongly abducted is kept in a plaster bandage six weeks; 




Fig. 81. — Upper part of normal femur 
(In the Warren Museum.) 



DEFORMITIES OF CHILD-GROWTH. 



147 



when the bandage is removed and the extremity slowly brought 
straight in bed, motion is encouraged early without weight-bearing 
and a protection splint worn for a year. 

Traumatic Coxa Vara. — Fracture of the neck of the femur in 
childhood, though unrecognized till recently, is not an uncommon 
accident, since radiography has been added to our methods of phys- 
ical examination. 

It differs in symptoms and 
effects from fracture in later 
life. The child patient some- 
times can walk in a few days, 
the fracture then is a green- 
stick one, — a bending or break- 
ing of the neck without actual 
separation of the fragments; 
and the limp and discomfort 
may be mistaken for hip disease. 
There is always a history of in- 
jury, often a fall from a tree, 
with limping and pain enough 
to keep the bed several days, it 
may be even weeks. Shorten- 
ing from a half inch to an inch 
shows with a corresponding rise 
of the trochanter above Nela- 
ton's line. Hip motion is re- 
stricted in flexion, abduction, 
and inward rotation more than 
in other directions, and as al- 
ready noted the immediate effects of the injury are less than in the 
adult. The deformity increases later on because the approach to a 
right-angled position of the neck exposes it to greater strain, and in 
old untreated cases the increased shortening and permanent adduc- 
tion make it indistinguishable from other forms of coxa vara. 

The condition has been studied by Whitman, of New York, who 
first called attention to its importance and frequency. 




Fig. 82. — Coxa vara. (Warren Museum .) 



148 



ORTHOPEDIC SURGERY. 




Treatment. — Whitman, if the patient be seen soon or a few weeks 
after the accident, or before consolidation is complete, attempts to 
replace the neck in proper relation with the shaft by forcing the limb 
into extreme abduction and fixing it in this position by a plaster 
bandage from axilla to toes. This forcible abduction of the thigh 
may be the means of replacing the neck of the femur in its normal 
relation with the shaft, because the rim of the acetabulum on which 
the trochanter impinges acts as a fulcrum, the shaft as the lever, 
while the lower border of the strong capsular ligament fixes the head 
IO qo of the femur so that the neck is by it bent 

back into place. When the normal limit 
of abduction is reached compared with 
the sound limb, the deformity has been 
completely reduced. The first plaster 
bandage should be worn six w r eeks, after 
which a short spica bandage with lessened 
abduction is worn and later a traction hip 
splint Chapter XXI, page 364. Full use of 
the limb should not be allowed for four 
months, or if painful for a still longer 
time. As a rule, the neck of the femur 
gives way some distance from the epi- 
physeal junction in childhood; in adoles- 
cents, however, the new bone near the 
Coxa vara with epiphyseal cartilage appears to be the 
at ioo° with weak point. Epiphyseal separation is rare 
as compared with fracture of the neck of 
the femur, according to Whitman; it may occur in adolescence or in 
childhood, and often in those who already have the coxa vara de- 
formity. Abduction of the thigh would be the attitude most likely 
to approximate the fragments in true epiphyseal separation also. 
Firmly united cases in which abduction is lost, may be cured by 
sub-trochanteric osteotomy, either linear or cuneiform, and reten- 
tion in an abducted position. Whitman removes a w r edge of bone, 
leaving a portion of the cortex uninjured on the inner side of the fe- 
mur, opposite the trochanter minor; the thigh is then gently abducted 



Fig. 83.- 
short neck 
shaft. 



DEFORMITIES OF CHILD-GROWTH. 



149 



and after the trochanter and neck come in contact with the upper 
border of the acetabulum, further abduction closes the wedge-shaped 
opening. This attitude is retained in a plaster spica bandage until 
union is complete. Whitman uses the short hip splint or the Lorenz 
spica, for, as the continuity of the femur is unbroken on the inner 
side, there is no danger of displacement of the fragments; he allows 
the patient to walk upon the limb in a few weeks. This method 
is only for children. In young adults fracture of the neck of the 
femur is unusual, and Whitman has found it associated with a back 
ward displacement of the head or neck of the femur, so that the 
limb is rotated outward, and there is a marked limp. This rotation 
as well as the adduction may be remedied by linear sub-trochanteric 
osteotomy. 



145 



COXA VALGA. 

Coxa valga is the reverse of coxa vara, a steep inclination 
of the neck of the femur over 140 . It has been found in about 
one percent of the femora in museums and may be associated 
with fractures, infantile paralysis, rickets, 
osteomalacia, osteomyelitis, knock-knee or 
congenital dislocation of the hip. David 
describes a congenital form of coxa valga, 
and it follows disuse in amputation stumps. 
Galeazzi describes a hip dislocated by paral- 
ysis where a high grade of coxa valga was 
attributed to the unopposed action of the 
psoas muscle in skating and walking. The 
deformity may also arise without apparent 
cause from growth. It may be double or 
single, more frequently the latter; it may 
follow the use of forceps in a breech delivery, Fig. 84. — Coxa valga. 
causing an epiphyseal separation or incom- (Warren Museum.) 
plete fracture of the neck as reported by Young. It is commoner 
in boys than in girls. 

The diagnostic signs are real lengthening of the leg from a half 
inch lo an inch; an abducted position of the hip with outward rota- 




150 ORTHOPEDIC SURGERY 

tion; inability to adduct; flattening of the side of the buttock from 
absence of the fullness of the trochanter; lowering of the trochanter 
so that the top lies an inch or so below Nelaton's line instead of 
close below it; and the peculiar gait, leaning far over to the affected 
side whenever the weight falls on the affected hip. 

The symptoms in little children come insidiously, the child learns 
to walk late, or limps leaning far to one side if the deformity be 
single, or rolls like a sailor if the deformity is double, raising the 
feet but little and bending the supporting knee before the advanced 
foot reaches the ground; they fall easily and find it hard to rise; 
they tire easily, and sometimes have pain and tenderness about the 
glutei and abductors, and sometimes spasm. 

Treatment. — David and others under anaesthesia have forcibly 
adducted and retained the limbs in plaster with inward rotation. 
Tenotomy has been tried by Young, with fixation in plaster. Gale- 
azzi, of Milan, divided by osteotomy the base of the neck where it 
joins the shaft, using an anterior vertical incision and closing the 
wound tight; putting the patient to bed with slight traction and 
watching the gradual rise of the trochanter by frequent radiographs. 
When the desired amount of shortening was reached a long plaster 
spica bandage was applied; walking without w r eight-bearing was al- 
lowed in three weeks. He reports an excellent functional result 
in two cases a year after operation. 

BOWING OF THE FEMUR NOT DUE TO RICKETS. 

The vast majority are due to rickets, but in a certain number it 
plays no part. The accompanying illustration and radiograph 
show the condition in a child recently at the Good Samaritan Hos- 
pital, Boston. At birth, in order to start respiration, the hot and 
cold water plunge was employed. Accidentally one leg was dipped 
into boiling w T ater and cicatricial contraction from the scald flexed 
the leg on the thigh and almost attached the heel to the buttock. 
Under the restraint of the scar, the bones grew and after five years 
anterior bowing was marked. Growing bones owe their shape to 
external forces and change of shape depends upon the stiffness and 
resistance of the bone in proportion to the force. 



DEFORMITIES OF CHILD-GROWTH. 



151 




Fig. 85. — Bowing of femur and leg from restraint of cicatrix. 
(House of the Good Samaritan, Dr. A. W. George, Radiographer.) 



152 ORTHOPEDIC SURGERY. 

BOW-LEGS NOT DUE TO RICKETS. 

The common cause of bow-legs is rickets but it may be seen in 
vigorous infants who stand and walk early when the force of weight- 
bearing affects a bone too soft to support the weight of the body. 
Adolescents get bow-legs from tardy or adolescent rickets. Bow- 
legs are not uncommon in adults and is the popular attribute of 
strength and activity. It is said to be common among men who ride 
horseback; but these people generally do not know that their legs 
were straight in childhood. Probably any force acting every day 
on the long bones, whether muscular, static, or due to occupation, 
may produce in time a curvature even in the bones of an adult, 
for they, like the soft parts, are continually undergoing changes an- 
alogous to growth. 

KNOCK-KNEE NOT DUE TO RICKETS. 

Knock-knee is usually the result of rhachitic softening; but it may 
be due to other forces acting upon growing bone and may express 
the result of growth under the restraint of the long-standing use of 
orthopedic appliances in which the pull of some of the straps has been 
used unwisely; or it may represent an overgrowth of the epiphysis 
from the presence of bone inflammation in the juxta-epiphyseal 
region where the increased blood supply causes increased growth. 
If a focus or foci of bone inflammation be confined to the internal 
condyle of the femur, for instance, the inner half of the epiphyseal 
disc of cartilage receives more blood and grows faster than the outer, 
and results in knock-knee, so it is a common complication of tumor 
albus. 

BACK KNEE. 

Back knee, genu recurvatum. This deformity may be a con- 
genital distortion of the knee-joint, or it may result from rickets 
or fracture of the femur or tibia, in which case the femur 
may be curved sharply forward above the joint or the tibia 
may bend sharply forward just below the head. It may also 
arise from the effect upon the growth and mechanics of the knee- 



DEFORMITIES OF CHILD-GROWTH. 



153 



1 



joint of an equinus position of the foot, for the attempt to place the 
heel upon the ground may then induce it, or it may be caused by 
the use of a traction splint for hip disease, 
and in some cases of recovery with shorten- 
ing a backward knee in the sound leg may 
compensate for the shortening. It is often 
combined with knock-knee or abnormal 
mobility of the joint, and may develop 
from causes unknown and be regarded as 
an error of the child's growth. It fre- 
quently causes no discomfort or a pecu- 
liarity of gait. This distortion should be 
recognized at a glance. Treatment is 
necessary only when there is disability. A 
simple caliper splint with leather behind 
the knee to prevent hyperextension will 
often allow the ligaments to shorten again 
to their normal length in a growing child. 

HOLLOW FOOT. 




Fig. 86. — Talipes equinus 
and back knees. 

Chapter XXI, page 375. 



While hollow foot, non-deforming club-foot, or contracted 
foot, as it is sometimes called, may be an inherited peculiarity or 
may often be traced to infantile paralysis or neuritis, it may arise 
from short shoes or simply come without assignable cause or be the 
expression of disproportionate growth, for the muscles, fasciae and 
ligaments all are shortened as if they belonged to the skeleton of 
a smaller foot. There are often no symptoms and the high arch 
is considered beautiful. On the other hand, some have difficulty 
in getting comfortable boots. The upper leather and the lacing 
irritate the dorsum and may set up inflammation of the bursae, or 
cause exostoses over the cuneiform bones, a condition popularly 
known as hump foot, pes cavus, pes arcuatus, pes excavatus. Jeanne 
has described changes in the scaphoid and cuboid also. Calluses 
and corns may come beneath the heel and the heads of the meta- 
tarsals. Pain is transitory and is apt to be in the great toe, the 
arch or the sole of the foot. The patient turns his ankle easily, 



*54 



ORTHOPEDIC SURGERY 



pounds upon his heels and turns the toes out and in some cases 
strongly in. Dorsal flexion is limited, and the plantar fascia is 
short. The amount of equinus is so slight that the foot can come 
to a right angle with the leg but not beyond it. The limitation of 
dorsal flexion may be demonstrated by asking the patient to flex 
his foot while standing erect with his back to the wall, when in spite 
of strong effort the feet remain "glued to the floor." 

Treatment. — Post-paralytic cases usually need tenotomy of the 
plantar fascia, of the tendo of Achillis, the flexor longus digitorum 
and the flexor hallucis tendons, with forcible wrenching or stretch- 




Fig. 87. — Hollow 
foot, pes cavus. 




Fig. 88. — Testing a pes cavus, 
for short tendo Achillis. 



ing, followed by fixation in plaster-of-Paris for three weeks and sub- 
sequently the use of a club-foot shoe or some similar ambulatory 
apparatus. Appliances for forcible stretching have been devised 
by Beely, Reddard and Shaffer, in which forcible correction is obtained 
for short periods of time daily, and is to be combined with the 
use of the club-foot shoe. Correction under ether with the Thomas 
wrench or the Lorenz or Schultze's osteoclast may also be employed 
without tenotomy and is immediately corrective followed by a cor- 
rective bandage, but excepting in little children tenotomies are usu- 
ally necessary. It is well to incorporate a small thin board, shaped 
to the outline of the sole of the foot, into the plaster bandage in order 
that firm, even pressure may be exerted. Massage and exercises 
should be used during the time the club-foot shoe is worn. These 



DEFORMITIES OF CHILD-GROWTH. 155 

cases are very apt to have a relapse and may need operation a num- 
ber of times. 

Laurenz has operated for a severe contraction of the foot by 
excising the scaphoid and the cuboid bones through separate inci- 
sions, after trying other procedures in vain. The feet were thus 
shortened about ^ inch and no motion was permitted where the resec- 
tions had been done. The result was a very useful pair of feet not 
deformed. 

Another operation was devised by Sherman, of San Francisco, 
because of the difficulty of holding the foot in position while the 




Fig. 89. — Non-deforming club-foot or hollow-foot. 
(Children's Hospital.) 



tendons are sutured; after tenotomy of the fascia and tendons and 
loosening up with the wrench and hand to correct the deformity, 
Sherman applies a plaster bandage in the overcorrected position. 
After it sets, a window is cut from the dorsum large enough to expose 
the field of operation; the foot is thoroughly cleansed and enveloped 
in a sterile gauze handkerchief before applying the plaster, so that 
cutting the handkerchief exposes a clean operating field. He then 
turns back upon the dorsum of the foot a quadrilateral flap, cover- 
ing the dorsal surface of the whole metatarsal region. The exten- 
sor proprius pollicis tendon is picked up, cut behind the head of the 



156 ORTHOPEDIC SURGERY. 

first metatarsal bone, and turned back from its sheath; the perios- 
teum so exposed is incised and separated to either side; two chromic- 
ized catgut sutures, each having a long, strong, straight Hagedorn 
needle on either end, are passed transversely through the tendon 
about half an inch from its cut end; then one needle is passed on 
either side of the bone between it and the reflected flap of periosteum 
through the sole of the foot and plantar part of the plaster, the other 
pair of needles are used in the same way; the sutures are tightened 
and tied on the outside of the plaster holding the tendon tight to 
the metatarsal and the flaps of periosteum are sutured over it. On 
the small toes one suture is enough to hold each tendon in place. 
After the last tendon is sutured the flap is replaced and sutured, a 
proper dressing is put on, followed by a reinforcing plaster-of-Paris 
bandage to retain all the dressings and to strengthen the splint, 
which, unless some reason forbids, is left undisturbed for from six 
to eight weeks. The foot should be in a position of slight dorsal 
flexion at the ankle. The only mishap has arisen from using too fine 
catgut to hold the extensor proprius pollicis tendon. In removing 
the plaster it is necessary to see that the foot is not fastened to it by 
unabsorbed sutures. 

FLAT-FOOT. 

Flat-foot, a generic term, includes all deformities of the foot 
which have pronation, from slightly weakened or pronated feet to 
stiff, broken-down feet with convex or "rocker soles." It is also 
called splay foot, pronated foot, in German, Plattfuss, pes valgus, 
pes flexus, pronatus reflexus, French, pied bot valgus, pied plat, 
Italian, piede spianato, Spanish, pie piano. 

It is about the commonest deformity the orthopedist sees. About 
62 percent arise between the ages of 10 and 25 years and one-third of 
the cases are found between 15 and 20 years. It is slightly more 
frequent in boys and young men; and it is more often double than 
single. The cause may be congenital, traumatic, paralytic, rhachi- 
tic, and static. About 90 percent are static, and the rest evenly 
divided among the other causes. 

Static flat-foot comes from weak muscles, i mproper attitudes in 




DEFORMITIES OF CHILD-GROWTH. 157 

standing or walking, improper restraint from stockings or shoes, 
often from all combined. In the infant's foot there is a pad of fat, 
described by Dane, under the bones in the sole which prevents break- 
ing down of the arch during the early days of walking until the mus- 
cles get strong to support it. The infant stretches his toes in all 
directions; both the great and little toe abduct freely from the long 
axis of the foot and the inner border of the foot is straight. The 
adult who has never worn shoes has usually the same type of foot, 
only more muscular; the prehensile toe may be acquired and is much 
used by some bands of savages. Bootless savages do not always 
exhibit this form of foot; some stand and walk badly, that is with 
pronation. The modern boot or shoe cramps and distorts the front 
of the foot, causes a loss of 
power, stiff crooked toes, and 
permits little or no use of the 
intrinsic muscles of the foot; 
all this favors flattening and 
pronation. 

The skeleton of the foot is 
formed of an outer and an 
inner arch. The outer con- 
sists of the OS calcis, the ^ig^ 90.— Flat feet with pronation 

and flattened arch. {House 0} Good 
cuboid, and the two outer Samaritan.) 

metatarsal bones; the inner, 

of the astragalus, scaphoid, the cuneiforms, and the three inner 
metatarsal bones. The strong articulation between the astragalus 
and the os calcis joins the two arches, but the joint facets on the 
calcis are not horizontal; they incline so that they direct the astragalus 
under pressure forward and inward. In standing the weight forces 
the astragalus to twist forward and inward upon the os calcis, caus- 
ing a slight pronation and rolling inward of the foot, and a lowering 
of the front of the os calcis; and while the outer arch is depressed 
under load the inner arch rolls slightly inward and away from it. 
This is the position of relaxation. It is permitted by the inefficiency 
of those muscles whose tendons cross the sole, the tibialis posticus 
and peroneus longus. 







158 ORTHOPEDIC SURGERY. 

Deformity. — Three deforming factors vary the appearance in flat- 
foot: (1) the dropping inward of the foot, (2) the flattening of the 
arch, and (3) the abduction of the front of the foot. In treatment 
much depends upon the recognition of these factors separately. 
Slight amounts of fatigue and pain, more often in the leg than in the 
foot, characterize the slighter degrees of pronation which are called 
"weakened foot." Abduction of the fore-foot with no flattening and 
little pronation is also sometimes seen. Marked pronation deformity 
is called by the Germans " Knickfuss," broken-foot, although the foot 
unweighted may still be normal in shape. Anatomical studies of the 
foot by Dane, Lovett, and Cotton show that the amount of pronation 
is in proportion to the amount of rotation of the astragalus. Looking 
at the broken-foot from the rear the heel inclines outward and the 
tendo Achillis is directed in a sweeping curve inward and upward 
instead of rising vertically. The terminal phalanx of the great toe 
is often raised off the ground. Patients get tired easily and suffer 
pain in the foot, heel, sole, base of toes, and calf of leg. They turn 
the toes out hence a diagnosis can often be made at a glance. The 
broken-foot which returns to a normal position when relieved of 
weight may remain such for years, or may soon pass into severe 
permanent deformity. The commonest cause of this form is undoubt- 
edly bad shoes. Once the position of pronation is assumed other 
factors act to increase the deformity. If the bones are softened by 
rickets and the muscles are weak it is easier for deformity to arise, 
but the majority arise in adolescence from bad static conditions. 

Diagnosis. — The diagnosis of flat-foot is usually easy. For record 
an impression made by the sole of the foot on paper is useful; it is 
made by simply wetting the foot or oiling it, and causing the patient 
to step on the piece of paper, or paper previously blackened over a 
candle-flame may be used and the impression "fixed " like a charcoal 
drawing. Freiberg moistens the sole of the foot with a solution of 
chloride of iron and stains the imprint on paper; by immersing this 
paper in a tannic acid solution the stain becomes a durable black. 
Bradford, Lovett and Dane observe the pressure mark of the sole 
by standing the patient on a glass top table and seeing the impress 
in a mirror placed beneath at an angle of 45 . 



DEFORMITIES OF CHILD-GROWTH. 1 59 

Treatment. — Treatment aims to restore the arch of the fool 
and prevent subsequent collapse. Severe cases of congenital flat-feet 
may be corrected in infancy by manipulations, massage, and fixation 
in supination and plantar flexion, by means of little splints or plaster- 
bandage. Older rhachitic children with severe deformities require 
forcible correction and retention in plaster bandages for four or 
six weeks, followed by massage and exercises and sometimes a plate. 
Static flat-foot, from bad shoes, requires attention to correct mal- 
positions of standing and walking. Shoes should be provided which 
adduct or bend the forward part of the foot in. Prolonged stand- 
ing should be prohibited. Walking should be done always with the 
toes directed straight forward. The raising of the arch is best accom- 
plished by gymnastic exercises. The following are serviceable : 

i. The patient with feet directed forward and slightly separated 
rises and sinks on his heels, using the toes as much as possible. 

2. The patient stands with the tips of the toes pointing as far 
inward as possible with heels turned out, raises and lowers his heels, 
retaining the outward direction of the heels. 

3. The same exercise is repeated, bending the knees as the heels 
are raised each time, straightening the knees as the heels are lowered. 

4. The patient sits with outstretched knees and rotates the toes 
in a circle inward, downward, outward and upward. 

5. Resistive movements; the surgeon offering the greatest opposi- 
tion to supination. 

6. The patient walks on the outer borders of his feet as if he had 
club-foot. 

Exercises should aim to attain a flexible foot and elastic gait. 

Hovorka makes his patients walk along a board six inches wide 
planed to incline like a barn roof, one foot on each inclined surface. 
Patients whose occupations make it impossible to avoid long stand- 
ing should relieve the position from time to time by rising on the toes; 
they must realize that their own interest and will power must co-op- 
erate, as plates alone will not do. A confirmed valgus position fre- 
quently requires a support for the sole of the foot which should be 
used temporarily. The Thomas' and Miller's boot raise the median 
border of the sole of the foot from heel to toe. Beely raises the 



i6o 



ORTHOPEDIC SURGERY. 



heel only and makes it run obliquely forward on the inner side to 
support the front of the calcis. A wedge-shaped piece of cork or 
rubber may be used inside of the boot to raise the inner border of 
the foot. Plates and pads have been used very extensively for the 
support of the weakened arch of the foot. They should extend from 
the heel to the ball of the foot and support both the outer and inner 
sides at Chopart's articulation. They should be made on a plaster 
cast of the foot, the arch being accentuated by the position in which 
the foot is held during the mold taking and further raising obtained 
by cutting away portions of the cast. Steel, aluminum-bronze and 
celluloid are the materials. The use of the flat-foot plate is becom- 
ing less frequent. It has the disadvantage of making the foot less 

flexible and causing the patient 
to rely upon the support of his 
plate and to neglect exercises. 

W. R. Townsend calls atten- 
tion to the abuse of plates. Many 
forms of plates are for sale in the 
shops and advertisements in the 
newspapers promise instant cure. 
One should remember that tem- 
porary relief may be obtained but 
not a cure if true flat-foot exists. 
Though reduction of the deformity may be gained, the patient who 
fails to cultivate normal movements of his foot will be weakened 
rather than improved, and a badly fitting support may do harm 
where a properly fitted one might be of service. 

Severe Grades of Deformity. — How is a stiff, unyielding flat-foot to 
be changed into a flexible foot ? Forcible correction under anaesthesia 
usually restores most of the lost flexibility; for a fortnight a plaster 
bandage maintains the position, after which a strong well-fitted 
plate will insure bearing the weight on the outer border of the foot, 
exercise and use should maintain the flexibility. In the less rigid 
feet a corrective apparatus may be worn for three or four weeks and 
afterwards a plate on which the patient exercises. That is to say 
rigid flat-foot is treated by temporary forcible correction and fixation, 




Fig. 91. — Forcible correction of flat- 
foot under ether. 



DEFORMITIES OF CHILD-GROWTH. l6l 

followed by correct walking, massage and gymnastics. The Thomas or 
Beely shoe is often useful. Sometimes it is difficult to regain strength 
enough to stand on the toes. Some cases of severe fixed flat-foot show 
considerable elevation of the posterior end of the os calcis with depres- 
sion of the cuboid; in these feet tenotomy of the tendo Achillis facil- 
itates correction. With care and attention practically all flat-feet 
undergo great improvement and most are cured. A certain number 
of surgical operations have been performed for the radical correction 
of resistive flat feet, (i) Excision of a wedge-shaped piece from 
the head and neck of the astragalus; (2) removal of the astragalus; 
(3) wedge-shaped resection of the astragalo-scaphoid joint; (4) 
linear osteotomy of the tibia and fibula close above the ankle. 




Fig. 92. — Operation of Gleich for cure of flat-foot. 

(5) Gleich, Trendelenberg, and Hoffa have tenotomized the tendo 
Achillis, and then through an incision as for a Pirogoff amputation, 
have sawed or chiseled through the os calcis from below upward and 
backward, separating it obliquely into a posterior and an anterior 
piece, the posterior is slid downward and forward into the sole; this 
shortens the foot slightly but restores the arch by making the tuber- 
cles on the posterior part of the bone lower than the front where it 
articulates with the cuboid. Excellent results have been obtained by 
the operation. 

(6) Shortening the tendon of the tibialis posticus by the method of 
Hoffa has also been efficacious. 

By rigid flat-foot is meant a painful foot with pronation 



l62 



ORTHOPEDIC SURGERY. 



or abduction caused by contracted muscles, in reality one fixed 
by muscle spasm. This condition is the result of sprain, generally 
a sprain of the astragalo-scaphoid joint, which may be hot and ten- 
der; other joints may be sprained. Lorenz has injected cocain sol- 
ution into the joint and as soon as it was cocainized the foot could be 
manipulated into any position painlessly; a plaster bandage retains 

the overcorrected position for two or three 
weeks when all sign of tenderness disap- 
pears. Rest by strapping, light massage 
and rest in bed or in a plaster bandage 
accomplishes the same thing as the cocain. 
Paralytic flat-feet are a group by 
themselves easy to recognize; they are to 
be treated according to the indications of 
the sort of paralysis present, for instance, 
if due to infantile paralysis it is remedi- 
able by tendon transplantation provided 
that a long enough time has elapsed to 
warrant its recommendation, for no one 

would do a muscle transference if nature 
Fig. qv — Cicatrix and foot • i-i i , ,1 i j i 

after operation. Figure 92. 1S llke l v to restore the paralyzed muscles 
in a few months. If the child be slowly 
regaining power in the muscles a suitable appliance like the one in 
Chap. XXI, page 382, may be used until such time as the operation 
is advisable. 

It is in the correction of paralytic flat-foot that tendon transference 
has been most employed. 




PAINFUL FOOT, METATARSALGIA. 

While weakness of the anterior metatarsal arch is often seen in 
static flat-foot it is then a secondary deformity, troublesome chiefly 
on account of calluses under the ball of the foot; it occurs primarily 
in the affection called painful foot, anterior metatarsalgia, or Morton's 
neuralgia. Typical cases of this painful affection have sudden cramp- 
like pains starting in the third or fourth metatarso-phalangeal 
joint and radiating to the tips of toes and up the leg. Its sudden 



DEFORMITIES OE CHILD-GROWTH. 1 63 

onset may be brought on by a miss-step or by the fatigue of stand- 
ing a long time and almost invariably it comes only when the shoes 
are worn. Sometimes attacks are infrequent, in others it practically 
disables the patient and it is provoked by inappreciable causes. The 
pain is so great that the patient removes the shoe, rubs and com- 
presses the front of the foot, flexes and extends the toes, and after a 
while the pain goes, leaving no sign or a very slight soreness over 
the articulation on deep pressure. The cramp-like pain may be 
referred to a single or to several adjoining joints or to -all the 
bones of the metatarsal arch. 

A disturbance in the normal relations of the distal ends of the 
metatarsal bones probably causes either a pinching of the plantar 
nerve between the bones or an abnor- 
mal strain upon the ligaments connect- 
ing the heads of the metatarsals, due 
to faulty footwear, insufficient room 
across the toes and consequent pres- 
sure on the metatarsals. 

The anterior arch of the foot is 
formed by the heads of the five meta- 
tarsal bones and the sesamoid bones 

beneath the ball of the great toe. The ^ 

Fig. 94. — Metatarsalgia: no 
second and third metatarsal bones are apparent deformity. 

slightly longer and on a higher plane 

than the others. Under the weight of the body in standing the 
arch is obliterated, to reform when weight is removed. When 
the arch is weak this resiliency is lost; yet Morton's neuralgia may 
be unaccompanied by deformity. Whitman considers that abnormal 
side pressure on the depressed articulations causes the pain, that it is 
similar to applying lateral pressure to the hand; if the hand is re- 
laxed the metacarpals are folded together and the arching is in- 
creased in depth, but if the heads of the metacarpals are fixed in a 
straight line the compression causes great pain at all the joints. The 
same is true of the foot. Besides the general effect of narrow shoes, 
some patients show evidence of an inherited predisposition and some 
have weakness from an old injury of the foot. 




164 ORTHOPEDIC SURGERY. 

Treatment. — Local treatment is to provide a proper shoe wide 
across the base of the toes so that they cannot be compressed later- 
ally, and some sort of support with a high arch to remove pressure 
from the heads of the metatarsals. As an immediate treatment a 
firm bandage suggested by Morton, or strapping may relieve the pain. 
A pad of felt or leather about an inch in size may be fixed to the sole 
of the foot with adhesive plaster to prevent depression of the arch. 
Young has modified this by attaching a pad of sole leather to the 
outside of the sole of the boot with excellent results. As a rule, a 
modified plate is a more comfortable support. It should be con- 
structed of No. 19 gauge steel upon a plaster cast of the sole of the 
foot in which the anterior and longitudinal arches have been some- 
what exaggerated by carving. The front of this plate should be at 
least as wide as the foot and extend forward to the line of metatarso- 
phalangeal joints. Massage and forcible manipulation to overcome 
restricted motions are of value after joint sensitiveness disappears. 
Rigidity may demand forcible correction under anaesthesia and a 
plaster bandage. Morton even rebected the neck and head of the 
metatarsal bone at the seat of the pain leaving the toe to recede 
Exercises to develop the intrinsic muscles of the foot are a necessary 
part of treatment. Repeated flexions and extensions of the toes, cir- 
cumduction of the front of the foot and picking up objects from the 
floor with the prehensile toe should be employed night and morning. 

PAINFUL FOOT FROM EXOSTOSES. 

Painful feet are often due to exostoses which may form 
most anywhere on the bones and especially close to the insertion of 
the tendons. Exostoses may be due to a general disease, like 
gonorrhoea, osteo-arthritis and syphilis, or they may grow from 
the irritation of bad shoes or repeated slight sprains due to habitual 
malpositions of the foot. The common positions for exostoses are: 

1. Hump foot on the internal cuneiform or base of the first met- 
atarsal. 

2. At the junction of the scaphoid and cuneiform. 

3. On the posterior part of the os calcis running up along the side 
of the Achillis. 



DEFORMITIES OF CHILD-GROWTH. 165 

4. On the inferior surface of the os calcis. 

They may be demonstrated by the X-ray, although at times this 
is almost impossible. 

Removal by surgical measures usually offers the best chance for 
comfort. Often a sole plate with depressions to remove pressure 
from the exostoses is efficient. The tender points on the sole found 
in gonorrhceal arthritis are not usually due to exostoses. 

The condition known as "policeman's heel," as it is a common 
condition in all city police forces, may be due either to exostoses 
under the os calcis, or to a bursitis of the subcalcaneal bursa, or to 
strain of plantar fascia from flat-foot with the pain referred to its 
calcaneal attachment. A plate to remove pressure from the tender 
place and to support the arch affords relief. 

HALLUX VALGUS. 

Outward deviation of the great toe is produced by adaptive 
growth under pressure of boots. In the normal foot the long axis 
of the toe prolonged backward passes through the heel. The great 
toe from boot-wearing deviates easily and it is not always a tight 
shoe which causes it, for the upper leather yields from use, stretches 
across the metatarso-phalangeal articulations, and presses on the 
side of the great toe as the foot slips forward and back in walking. 
Short boots and short stockings aid in producing it. The head of 
the metatarsal partly uncovered by the phalanx is pushed into a 
more prominent position under the skin, which thickens and a 
bursa forms beneath it. Inflammation of this bursa is a bunion. 
Non-inflammatory hallux valgus produces a gait characterized by 
pronation and loss of elasticity. Pain and irritation of the bunion 
joint may be mistaken for gout. Marked degrees of this deformity 
are seen in adolescents, and adults. Few of our children have a 
perfectly straight toe after the age of eight years. 

Treatment. — A slight degree of deformity may be cured by 
wearing light steel or rubber splint along the inner border of the great 
toe and foot. Even wearing a pledget of cotton between the great 
toe and its neighbor may accomplish this if the boots at the same 
time allow room for lateral expansion of the great toe. The toe 



i66 



ORTHOPEDIC SURGERY. 



post and digitated stockings are excellent. The foot plate is recom- 
mended when the foot is weakened or flat. In severe cases opera- 
tive measures are adopted. Resection of the joint may be done 
in several ways. 

R. B. Osgood lays bare the shaft of the metatarsal immediately 
above the head, isolates the bone with a flat metal retractor, passes 
with an aneurysm needle and silk guide a Gigli saw around the bone 
and sawing it off, removes the distal end of the bone holding 
the phalanx in place by a suture of chromicized catgut. This opera- 





Fig. 95.— Hal- 
lux valgus, great 
toe underneath. 



Fig. 96. — Hallux 
valgus. Great toe 
overrides. 



tion, like ordinary resection of the joint, produces a useful foot with 
some shortening of the great toe. 

Another operation, not a resection, opens the joint by a free longi- 
tudinal incision on the inner side, lays bare the whole metatarso- 
phalangeal articulation, and with a strong pair of bone cutters 
removes the inner aspect of the head and part of the shaft of the 
metatarsal bone, taking off all that protrudes beyond the phalanx; 
the sharp edges are pared off with a chisel, the phalanx replaced in 
a normal position, the incision closed, and the position of the toe 
maintained by a splint outside of the dressings. Passive motion is 



DEFORMITIES OF CHILD-GROWTH. 



167 



begun in two weeks, and voluntary motions are done early by the 
patient. Usually in three weeks time, the patient walks with a nat- 
ural gait, free from pain. 

HALLUX VARUS. 

Hallux varus, also called in-toe, pigeon toe, is rarely of import- 
ance. It is found with knock-knee and may be a symptom of 
that affection; it may be congenital or may accompany flat-foot. In 
young children the use of ordinary shoes is sufficient to correct the 
deformity. 

HALLUX RIGIDUS. 

Hallux rigidus, stiff toe, may be accompanied with slight flexion 
of the first and extension of the second 
phalanx, or the joint may be rigid in the |l 

straight position. It begins with a slight I 

sprain and painful joint motion; later, swell- / 

ing and tenderness involve both the joints 
and the bones. After ankylosis there is 1 I 

atrophy of the soft parts. Its frequent asso- I / 

ciation with flat-foot and with bad shoes sug- I I 

gests that it may result from neglected sprain. / \ 

At times it follows severe injuries, fractures, ^r s^ 
comminuted crushes of the foot, etc. Rest^'/ 
and local applications are indicated during 
the stage of acute sprain; later on, protection IC " 97 ' 
with a modified plate. 




-Hammer toes. 



HAMMER TOE. 

Hammer toe is a claw-like contraction usually of the second or 
third toe. The second phalanx is dorsi flexed, the third plantar- 
flexed, producing a callosity over the upward projecting joint and 
another over the tip of the toe where it presses on the ground. Bad 
boots, especially short boots, cause it. It may result from par- 
alysis. Slight cases give no trouble. Later on, the surgeon is asked 
to amputate. 



l68 ORTHOPEDIC SURGERY. 

Treatment. — Children and adolescents may be straightened 
by simple splints and strapping. The toes may be bandaged or 
strapped to a rigid plantar splint. If it fails to yield it can be cor- 
rected by subcutaneous section of the contracted fasciae and tendons, 
forcible straightening and fixation with splints and adhesive plaster. 
There is always a tendency to recontract. The use of splints must 
therefore be prolonged. In severe cases either amputation or exci- 
sion of the prominent joint may be done. Amputation of the second 
toe cures the deformity but it may produce hallux valgus. 

Konig calls attention to marked hammer toes with a contracted 
foot from short boots in soldiers of the infantry. Subcutaneous 
tenotomy of the flexor tendon of the great toe with the use of a wooden 
plantar splint during the three weeks required for the healing of the 
tendon was sufficient treatment. 

Flexed or clawed toes also arise from paralysis, and from hollow 
foot. The tendons and fascia? of several toes are shortened. The 
treatment is the same as for hammer toe. 



PART 111. 

AFFECTIONS OF BONES AND JOINTS. 



CHAPTER XI. 
THE BONES AND JOINTS: GENERAL SUMMARY. 

Many different processes in the bones and joints are classified 
as inflammations. 

For the sake of explaining, let us see what it is that is injured; 
the bones and the joints are made of different tissue structures; bones 
consist of bone, marrow, endosteum, periosteum and articular car- 
tilage; joints of a synovial cavity surrounded by the articular cartil- 
ages of the bones, the synovial membrane, capsule, ligaments, and 
peri-articular structures, the bursae and tendons; in addition they 
may contain an intra-articular cartilage or two. Each one of these 
things separately, and several or all of them may get into trouble 
in three ways: first, by a mechanical injury and repair; second, by 
true inflammation from the irritating presence of micro-organisms 
or of toxins, poisonous matters produced by them; and third, by 
changes due to disorders of nutrition, whether from impaired blood 
supply, or faulty metabolism of the tissues of the body, or trophic 
disturbance due to some disease of the nervous system. 

Let us take an example of how each one of these three processes 
affects the structure of bones and joints. 

TRAUMA AND REPAIR IN BONES AND JOINTS. 

Bones. — Bones consist of periosteum, cortical and cancellous 
bone, endosteum, marrow, and cartilage, — all tissues of varying 
vascularity. Injury of periosteum may give rise to simple hyper- 
emia and swelling, to traumatic periostitis, to subperiosteal hemor- 
rhage, or periosteum may be cut or stripped up in shreds by mechan- 
ical violence. Injury of bone is usually a fracture which may be 
complete or incomplete, etc.; a small piece of bone may be torn 
away in the attachment of a ligament or tendon; and, in rare in- 
stances, a layer of cortical bone, if close under the skin, may be 

171 



172 ORTHOPEDIC SURGERY. 

so injured by a blow that it dies and is cast off as a sequestrum. In 
fractures, marrow, periosteum and endosteum, and if into the joint, 
the articular cartilages are all injured. The process of repair of 
these conditions is described in works on General Surgery. 

Joints. — Joints usually consist of a synovial cavity surrounded by 
articular cartilages, synovial membrane, capsule, ligaments, and peri- 
articular structures. Injuries and repair are seen in dislocations 
where all structures suffer somewhat from mechanical violence. 

As an instance of the injury of a single tissue in the joint may be 
mentioned the condition known as dislocation of the semilunar car- 
tilage of the knee-joint. Through some sudden twist or fall, one of 
these cartilages is uprooted, displaced, and perhaps torn across. 
The knee is instantly locked in the flexed position, there is great 
pain, and the joint rapidly fills with serous effusion, nature's method 
of separating the bones and allowing the cartilage to resume its proper 
place. 

It untreated, it slowly re-absorbs, and after a varying time, the 
patient goes about again, but is liable to repeat the performance. 

In partial dislocations the injury is less serious, but all in- 
juries of joints produce this acute synovitis, which is not, as its name 
implies, a true inflammation of the joint but an oversecretion of 
fluid from the synovial membrane due to nature's process of repair. 
Effusions in the synovial cavity may also be produced by the 
irritating action of bacteria or toxins, but the fluid then is usually 
not a clear serum, it is either cloudy or contains fibrin. 

After an injury the effusion in a joint may be blood; a joint rarely 
fills with solid blood as the result of injury unless from a com- 
minuted fracture into the joint, or unless the patient is a born 
bleeder; bleeder's joints are interesting and the changes which fol- 
low in the track of repeated attacks are like those of chronic inflam- 
matory disease or of some diseases of unknown etiology usually 
attributed to derangements of nutrition. 

The first effusions may be absorbed entirely or some masses of fib- 
rin remain. In succeeding attacks, however, this fibrin becomes organ- 
ized into fibrous tissue and the knee is often subluxated and the 
process ends in complete loss of motion and fibrous ankylosis. 



AFFECTIONS OF THE BONES AND JOINTS IN GENERAL. 1 73 

Injuries of joints are accompanied by injuries of the peri-articu- 
lar structures, but sometimes these suffer and the joint itself 
escapes. As an instance of peri-articular injury and repair the stu- 
dent should remember tenosynovitis, a non-infectious inflammation 
of the sheaths of the tendons usually seen at the wrist and ankle. As 
the tendons and their sheaths are but slightly vascular their repair 
is slow. The student should bear in mind the histological appear- 
ances characteristic of the conditions of bones and joints incidental 
to repair. 

TRUE INFLAMMATIONS OF THE BONES AND JOINTS. 

These are processes caused by the irritating presence of micro- 
organisms or their toxins. 

Bones. — Periosteum. True periostitis is due to infection with 
pyogenic micro-organisms and is associated with infection of the 
bone, osteomyelitis. Suppurative periostitis may strip the perios- 
teum very extensively and separate it from the whole shaft of a 
bone, and kill it, unless an exit be made early for the pus. Perios- 
titis from syphilis is a well-recognized part of that disease and leads 
to proliferation. Periostitis from actinomycosis leads to prolonged 
suppuration but usually confines itself to the superficial layers of the 
cortical bone of the jaw, ribs and spine. 

Bone and Marrow. — Osteomyelitis is invasion of marrow of can- 
cellous bone, the cortical bone canals and spaces with colonies 
of micro-organisms which, by their irritant action, set up sup- 
purative inflammation. This inflammation is confined at first to 
the bone marrow and endosteum. Periostitis may occur with it, 
due to a superficial osteomyelitis or a breaking through of deep 
seated suppuration. The process is destructive; its degree of de- 
structiveness depends upon the virulence of the attacking organism. 
Necrosis may cause the formation of large sequestra which 
are not unusual. According to the degree of virulence of the or- 
ganism we may have an acute, or a subacute, or a chronic form 
of inflammation. The seat of the first focus of infection 
is often near the epiphyseal disc in children. In infants and 
young children where the epiphysis is still largely cartilage and, 



174 ORTHOPEDIC SURGERY. 

occasionally, in older children primary foci of infection may come 
within the epiphysis, and the substance which is inflamed be either 
cartilage or the new-formed bone of the center of ossification. Sup- 
purative epiphysitis of infancy soon breaks into the joint so it is 
called both an acute epiphysitis and an acute arthritis; but the 
primary seat of invasion is in the epiphysis not the joint. Except in 
infancy pyogenic organisms rarely attack the epiphysis, tuberle bac- 
illi almost always select the epiphysis. Acute epiphysitis is a very 
destructive process; unless arrested by providing early drainage for 
the pus, an entire joint may be destroyed in a week. 

Joints. — Acute arthritis is an acute septic inflammation or a pus 
joint arising from septic invasion which may be primary or secondary 
to some other point of septic inflammation, or be secondary to epi- 
physitis as we have already seen. Its effect on the joint is even more 
destructive than osteomyelitis is on the bone, but, of course, the 
destructiveness varies with the virulence of the infecting microbe. 
Unless nature or the surgeon provides early drainage, the synovial 
membrane, cartilage, capsule, ligaments, and ends of the bones them- 
selves may melt away under the suppuration. All the structures 
show inflammation even in the milder, more subacute forms, where 
instead of true suppurative inflammation in the joint one finds a 
slightly cloudy fluid with masses of fibrin. 

This condition, spoken of as subacute arthritis occurs as a com- 
plication of acute infectious diseases, like measles, scarlet fever, 
typhoid fever, small pox, etc., although sometimes the acute and 
destructive pus joint is present in these diseases. 

CHRONIC TRUE INFLAMMATION OF BONES AND JOINTS DUE 
TO MICRO-ORGANISMS. 

Syphilis and tuberculosis are general inflammatory diseases 
characterized by a granulomatous inflammation. The bones are 
primarily involved; the joints secondarily. 

Hereditary syphilis in infancy may produce extensive destruc- 
tion from joint suppuration. Syphilitic dactylitis in young chil- 
dren is due to the destructive action of a gumma ; both the bone and 
the joint are destroyed, and it involves one or more of the metacar- 



AFFECTIONS OF THE BONES AND JOINTS IN GENERAL. 1 75 

pals, or phalanges. Syphilis in the bones of older children and 
adults is less destructive, has more of the characteristics of a chronic 
proliferating periostitis or of a subacute arthritis unless a gumma 
happens to develop. 

Tuberculosis is, likewise, as a rule, more acutely destructive in 
early infancy than later on. The well known and carefully studied 
characteristics of tuberculosis of the different joints will be considered 
separately later. 

Extra-articular or peri-articular structures undergo inflammation 
and simulate joint disease or produce arthritis by a direct spread- 
ing of the inflammation. One of the commonest of these peri- 
articular inflammations is the bursitis or abscess of the prepatellar 
bursa, known as housemaid's knee. As a chronic process there 
is the adhesive bursitis of the subacromial bursa which causes chronic 
stiff shoulder. 

THE AFFECTIONS OF BONES AND JOINTS DUE TO DISORDERS 
OF NUTRITION, ETC. 

The structures of bones and joints may be affected by quasi- 
inflammatory changes due to disorders of nutrition either from 
faulty metabolism of the whole body, faulty blood supply, or faulty 
trophic conditions produced by disease of the nervous system. These 
conditions are imperfectly understood. It is not known that disor- 
ders of nutrition are present in all the diseases classified here, but an 
intimate resemblance in the symptoms and pathology has led the 
writer to class them together simply for the convenience of the stu- 
dent. 

DISORDERED NUTRITION OF BONE. 

Bone. — The periosteum is affected in scurvy of infancy and occa- 
sionally in rickets, by subperiosteal hemorrhages which may be very 
extensive and may denude the entire shaft but its most frequent seat 
is just above the epiphysis in the long bones. In rickets the peri- 
osteum is thickened and beneath it is formed instead of a deposit of 
true bone, some cartilage and some osteoid tissue mixed. Sub- 
periosteal hemorrhage in rickets occurs chiefly in those rare cases 



176 ORTHOPEDIC SURGERY. 

where fractures occur spontaneously. Both scurvy and rickets are 
diseases of malnutrition. 

Rickets. — Rickets is a general nutritional disease of childhood 
which affects the growth of the bones all over the body. In the 
long bones there is an irregular proliferation between the epiphysis 
and the shaft of soft " osteoid" tissue, producing an increased 
width of bone where the epiphysis and shaft join; the shafts of the 
bones also are weakened so that they bend under the body-weight 
or the pull of the muscles. It is a disease of early childhood, 94 
percent begin before the age of four years, but there are tardy 
cases coming late in childhood, and adolescent rickets are sometimes 
seen. 

Osteomalacia. — Osteomalacia is another nutritional derangement 
characterized by the disappearance of lime salts from the bones, 
leading to softening, bending and fracture. There is a juvenile 
form which is rare, and an adult form which usually follows preg- 
nancy. 

Fragilitas ossium, brittle bones, occurs as a distinct fetal disease 
which is fatal within a year, and as an affection of children which 
is outgrown. They are characterized by frequent fractures, many 
of them spontaneous. Those beginning before birth represent a 
different disease because they show no sign of improvement and the 
patients die young; whereas, those beginning in childhood become 
strong later. The bones cast a feeble shadow by the X-ray. The 
same may be said of some cases of rickets and of osteomalacia — 
always in all these conditions the bones are thin and atrophic with 
large medullar}' cavities. The cause of imperfect bone formation is 
unknown, but it probably arises from a condition of impaired nutri- 
tion of bone. 

Hypertrophic Osteoarthropathy. — It seems paradoxical to say 
that disordered nutrition will cause enlargement of part of the skel- 
eton, yet this is undoubtedly what happens in secondary hypertro- 
phic osteoarthropathy, a disease of the bone characterized by hyper- 
trophy and clubbing of the fingers. There is a deposit of layers 
of new bone in the metatarsals, metacarpals, phalanges and occa- 
sionally in the distal extremities of the adjoining bones of the arms 



AFFECTIONS OF THE BONES AND JOINTS IN GENERAL. 1 77 

and legs, and is accompanied by an overgrowth of the nails. As its 
name implies, it is always a secondary condition, a complication 
of pre-existing chronic disease, most often of the lungs. 

Ostitis deformans is an affection of the bones of middle and ad- 
vanced life characterized both by hypertrophy and softening of bone, 
hyperostosis and decalcification. The legs bow under the body- 
weight, the bones become thick and large, the back is bowed, the 
skull enlarges; arteriosclerosis accompanies it almost invariably 
and may be the cause of the impaired nutrition. 

Acromegaly.— A condition of hypertrophy of the extremities of 
the body, — the hands, feet, fingers, nose, etc.; the head is increased 
in size and all of the tissues may undergo change. The people are 
often giants. The disease is supposed to be due to irritation of the 
pituitary gland, which has been found not infrequently sarcoma- 
tous. It has been said that the disease of the pituitary gland bears 
the same relationship to acromegaly that the thyroid does to myxce- 
dema. 

DISORDERED NUTRITION OF JOINTS. 

Charcot's Disease. — Charcot's disease is characterized by hyper- 
trophy of the periphery of the articular cartilages, with erosion at 
the points of greatest intra-articular pressure and eburnation of the 
underlying bone, and by sudden large serous effusions into the joints. 
Locomotor ataxia is the cause of this affection, which is a neurotrophic 
disturbance of the joint. A history of syphilis is obtained in many 
of the cases. 

Arthritis Deformans. — This disease of unknown origin is 
characterized by changes in the bones and joints resembling those 
of Charcot's disease, but unlike it there is no association with loco- 
motor ataxia or any other disease. It occurs in two types or forms, 
the hypertrophic and the atrophic, which are by some regarded as 
two separate and distinct diseases; they are here classed as types 
of arthritis deformans because pathologists usually find evidence 
of both processes at the same autopsy. 

The hypertrophic form is characterized by the formation of ex- 
ostoses around the borders of the joints; the atrophic, by a thicken- 



178 ORTHOPEDIC SURGERY. 

ing of the capsule and thinning and erosion of the articular cartil- 
ages and marked atrophy of the bones and of all soft parts in the 
region round about. Both forms are chronic and progressive and 
were formerly called chronic rheumatism or rheumatic gout. Under 
arthritis deformans were also described the chronic joint inflam- 
mations due to infections like gonorrhea, typhoid fever, the exan- 
themata, influenza, tonsillitis, and many mild infectious diseases, 
which rightly belong with chronic forms of septic joint disease, 
and are characterized by effusions in one or more joints with chronic 
thickening of the capsule and periarticular structures; and when 
several joints are affected they are all involved in a few weeks, 
after which there is no further spreading to other joints. 

" Gout is a constitutional disorder associated with excess of uric 
acid in the blood and characterized by attacks of acute arthritis and 
by the gradual deposit of urate of soda in and about the joints." 
In this country it is a rare disease. Gouty deposits are sometimes 
found after death in the joints of people supposed to have chronic 
rheumatism, arthritis deformans, where there was no history of an 
attack of acute gout. 

Functional Disease. — The remaining affections of the bones and 
joints are those in which pathological evidence of damage is want- 
ing. Hysterical joints are not uncommon in childhood and usually 
represent a neuromemisis, that is a prolonged continuation of the 
symptoms of an injury from which apparently complete recovery 
has been made, according to the physical signs. They are there- 
fore classed separately as functional joint diseases. 



CHAPTER XII. 



INJURIES AND DISEASES OF BONES AND JOINTS. 
MECHANICAL INJURY AND REPAIR. 

BONES. 

Periosteum. — Sub-periosteal hemorrhage or bruising of the bone 
is a condition frequently seen and little talked about. The exten- 
sive typical deformity of new-born infant's head known as cephal- 
hematoma is familiar to all. Through bruising in childbirth, the 
periosteum of the flat bones of the skull is, in places, raised by blood 
clots, which are very slowly reabsorbed; meanwhile the perios- 
teum at the margin of the clot, stimulated to proliferate, builds up a 
hard ridge of bone around the swelling, while underneath the clot, 
the surface of the bone is eroded, from malnutrition caused by the 
loss of the little arteries which penetrate the bone from the perios- 
teum to nourish it. The same process on a small scale takes place 
in a "bone bruise" which always takes several weeks to absorb. 

Slighter bruising gives rise to painful hyperemic swelling of the 
periosteum which has been described as traumatic periostitis, al- 
though no micro-organisms are present to excite inflammation. 

Occasionally, as the result of operation, small bits of periosteum 
may be stripped up and left. They may cause considerable dis- 
ability, for the periosteum slowly forms new bone which may restrict 
the motion of the joint. 

The writer recently saw such a case three months after an at- 
tempted reduction of congenital dislocation of the hip by open in- 
cision. The reduction had failed and a bridge of bone firmly united 
the pelvis and femur with the foot unfortunately in a bad position. 

The Tearing off of Ligaments and Tendons with Bone. — 
Rarely is a small piece of bone torn off by muscular action in the 
end of a tendon or ligament. Such is the so-called avulsion of 

179 



l8o ORTHOPEDIC SURGERY. 

tubercle of the tibia where, however, the actual separation is very 
slight. 

The tubercle of the tibia develops from the upper epiphysis as 
a long, thorn-like process extending downward over the anterior 
surface of the shaft. Ossification begins at puberty, it unites with 
the shaft in a year or two; it is during this time that avulsions have 
been reported. The muscular contractions must be very sudden 
and powerful. It is a rare accident and diagnosis should be 
corroborated by the X-ray. 

In complete avulsions immobilization with the leg raised to relax 
the quadriceps femoris muscle for six or eight weeks has been the 
treatment, but one surgeon drilled through the fragment into the 
shaft of the tibia and left his drill in to nail it there for three weeks. 
Osgood describes a partial separation of the tubercle which he could 
demonstrate by the X-ray, although the symptoms were very slight. 

Bone ; Traumatic Necrosis. — In rare instances a layer of cortical 
bone, superficially placed, may be so injured by a blow that it dies 
and is cast off as a sequestrum. That this process occurs without 
infection is a matter of some dispute among pathologists. The fol- 
lowing case points to its possibility. 

An infant of ten months rolled out of bed, striking the top of the 
head on the floor; swelling appeared which was treated for six weeks 
with cold applications; it then increased considerably in size, and 
a hematoma was drained by the physician. Two months later, the 
child was brought to the writer at the West End Infant's Hospital, 
and a thin plate-like sequestrum, the size of a fifty cent piece, re- 
moved. Nature's process of casting off necrotic bone and repairing 
damage is slow, even in infancy. 

JOINTS. 

The mechanical injuries of joints are sprains, fractures and dis- 
locations. Joint sprain generally produces what is called in the 
knee an acute synovitis. 

Acute Synovitis. — This process is common, one should be familiar 
with it not to confound it with other processes. From a slight injury, 
a slip, wrench, fall, blow, the knee swells, or the same may occur in 



INJURIES AND DISEASES OF BONES AND JOINTS. 



181 



the hip or in any other joint, but the large size and superficial sit- 
uation of the knee makes it both prone to injury and easy of obser- 
vation. The knee is therefore taken as an example of what may 
happen elsewhere. There is swelling, slight increase in superficial 
heat, motion is more or less restricted, the joint is habitually held 
slightly flexed, and the patella is found to float if the fluid is restricted 
to the space beneath it by the observer's hands which encircle the 
joint above and below and approach the patella. If untreated it 
persists for months, nature 
slowly reabsorbs the effusion 
and there is sometimes a full 
return of motion in the joint 
but often joint adhesions re- 
strict it. 

The Treatment should con- 
sist of immobilization with or 
without pressure, and rest to 
the joint; or, immobilization 
may be combined with mas- 
sage or in mild cases with free 
exercising of the joint. The 
process is sometimes hastened 
by quick superficial applica- 
tions of the thermo-cauterv 
followed by strapping. Rest, 
counter-irritation, massage, 
and occasional passive move- 
ments are all indicated but the process of repair is always slow, 
to seven weeks are required for the knee-joint. 

In the hip, a similar condition frequently simulates the early stage 
of tuberculous hip disease; but the symptoms subside quickly — in the 
course of five to twelve weeks there is a complete return to the normal. 

Simple effusions in sprains of wrist and ankle are common. 

Another example of joint trauma and repair is the dislocation 
of the semilunar cartilages of the knee-joint. 

Dislocation of Semilunar Cartilages. — The intra-articular car- 




Fig. 98. — Acute synovitis of right knee. 
(Children'' s Hospital.) 



-five 



152 ORTHOPEDIC SURGERY. 

tilages of the joint sometimes undergo injury as we have already 
seen. The knee is suddenly painful and locks itself, as the result 
of a slight twist; there is excruciating pain, and an effusion is rap- 
idly poured out in the joint. Such is the story of displacement of 
a semilunar cartilage. The cartilage has torn loose from its tibial 
attachment, — it may be the internal or the external one but the inter- 
nal is the one usually affected, and this is usually due to an inward 
rotation of the femur on the tibia which is fixed by the foot on the 
ground with the knee slightly flexed; the joint can be bent but not 
extended beyond a certain point, — it is locked. The attack of syno- 
vitis is sudden and sharp and its swelling soon masks the slight prom- 
inence made if part of the semilunar cartilage is protruding. It 
is rare in children; more men have it than women, — young men par- 
ticularly. 

To reduce the locked knee it should be fully flexed, the tibia drawn 
away from the femur and rotated in and out and the leg quickly 
extended but not forcibly, while the surgeon manipulates with his 
thumb the situation of the semilunar cartilages, should prominence 
be felt. Once in a while the knee refuses to reduce, but usually 
under anaesthesia reduction is easy and occurs with a click. 
Should the cartilage again unite to the tibia, all may be well. 
It may remain torn from its tibial attachment at its two ends 
or it may be torn across in the middle, or a torn piece may be wholly 
separated and become a loose cartilage in the joint. 

In 128 operations for the relief of injuries of the semilunar cartil- 
ages, collected by Tenney, 113 involved the internal and 15 the exter- 
nal cartilage. The immediate after-treatment is like that for syno- 
vitis but attacks recur and a more permanent cure is demanded. 
This may be mechanical or operative. An elastic knee-cap with 
pads beside the patella, or elastic bandages are of great use in pre- 
venting future attacks, but they are not always effectual and are often 
inconvenient. Shaffer's splint is described in Chapter XXI. It de- 
pends for its action upon securing a perfect hinge-like motion for the 
knee-joint and restricting complete extension and flexion by the use 
of a removable pin. A pad is also placed over the inner aspect of 
the knee. 



INJURIES AND DISEASES OF BONES AND JOINTS. 183 

The splint is especially valuable for those cases where the leg 
would lock from slight causes and stay so for a number of hours. 
The object of this treatment is to prevent harmful motions and 
positions for several months, so as to allow the cartilage time to 
unite again with the tibia. 

Operative treatment, however, often appeals to the patient be- 
cause be believes it surer and quicker. The joint is opened by 
a vertical incision a finger's breadth to one side of the patella and 
freely explored; the loosened part of the cartilage is excised and re- 
moved, the joint capsule sutured, and the wound closed; fixation in 
plaster is maintained for two weeks, followed by gentle manipulation 
and a gradual restoration of the use of the knee. 

Not infrequently, at the time of operation, there are found hyper- 
trophied villi growing from the synovial membrane about the region 
of the patellar ligament which can be removed. Sometimes tabs of 
fat, which represent a similar process further advanced, are removed. 

Villous Arthritis. — Villous arthritis designates a condition of the 
synovial membrane which may be due to injury, often results from 
strain from flat-foot, or may follow mild forms of bacterial infection, or 
it may accompany joint manifestions in the course of diseases affect- 
ing nutrition. The condition is, therefore, referred to in all three 
classes of joint affections. 

It is common in the wake of simple synovitis or in dislocation of 
the semilunar cartilages. The knee, shoulder, and elbow are the 
joints most commonly affected, — the knee especially. The folds of 
the synovial membrane in the knee, the ligamentum mucosum, and 
the ligamenta alaria, two fringe-like folds extending from the side 
of the ligamentum mucosum upward and outward to the patella, 
are the principal places for the growth of the villi, but sometimes 
villi grow all over the synovial membrane. 

These are at first little slender, warty projections, made up of a few 
small blood vessels and little else besides a covering of the synovial 
membrane but as they grow older and larger, the vessels disappear 
and the slight fibrous framework becomes transformed into fat. 
Masses of fibrin may adhere to these warty proliferations of syn- 
ovial membrane. 



184 ORTHOPEDIC SURGERY. 

Clinically, these villi give rise to what is known as dry arthritis, 
— bending of the joint calls forth creaking and snapping sounds 
plainly heard with a stethoscope and as a rule no excess of fluid 
forms in the joint. The affection, especially that which follows slight 
traumatisms of the synovial membrane, is extremely common and 
often is unnoticed; but as the folds which are near the patella lengthen 
out the fringes of villi occasionally are caught between the ends 
of the bones, in straightening the joint there is a great sudden pain, 
the joint is locked in a partly flexed position, and a synovial effusion 
begins to form rapidly. This makes them swell and the fringes 
get larger and more fatty, and are more apt to be caught again. 
Frequent repetitions cause the membrane to lose its elasticity and 
the synovial fringe to grow into a large loose fold with tabs of fat 
hanging at the periphery; when large it is called lipoma arborescens; 
in the knee villi are found near the patella although sometimes they 
form elsewhere on the synovial membrane. The fatty change is not 
the only one to take place in the tips of the fringes; bits of cartilage 
and dense fibrous tissue are formed sometimes and the loose cartil- 
ages known as joint mice are produced in this manner as they 
later separate from their attachments. Calcareous bodies as 
well as cartilaginous ones may originate in this way; or they may 
grow as little placques between layers on the walls of a smooth syno- 
vial membrane. Masses of coagulated fibrin, as we have already 
seen are frequently attached to the fringes, — sometimes the fibrin 
may be present in a mass an inch in diameter; these large coagula 
of fibrin have also been observed after inflammatory effusions in the 
knee-joint, such as tuberculosis and rheumatoid arthritis. They 
act as a foreign substance inside of the joint and irritate like other 
loose bodies. Lipoma arborescens is also found in tuberculous 
disease of the knee-joint. 

Treatment. — Simple counter-irritation and things which stim- 
ulate the circulation in the joint, such as baking, may be employed 
and, if the fringes are short, this is often sufficient. Partly 
restricting motion in the knee by strapping is of great value be- 
cause it limits the range of motion and prevents repeating the 
pinching of the fringes in the joint. In advanced cases where 



INJURIES AND DISEASES OF BONES AND JOINTS. 185 

this treatment fails, the joint should be freely opened and the 
fringes excised. 

A vertical incision, a finger's breadth from either side of the patella, 
gives a satisfactory field of operation. With proper aseptic precau- 
tions opening the knee-joint is not to be dreaded more than opening 
the peritoneum. Many are benefited by operation but some are not. 
The incisions should be sewed tight, (the capsule separately from the 
skin and subcutaneous tissue), sterile dressings applied, and immobili- 
zation in a plaster-of-Paris bandage from toe to groin should be 
maintained for a week or ten days. At the end of the second week 
the patient gets up on crutches and the splint is removed twice a day 
for slight voluntary movements. In the third week, the plaster is 
discarded, a flannel bandage substituted, and the patient begins 
to walk upon the knee. Hot and cold douching and massage are 
useful to get rid of the stiffness and moderate exercise should be en- 
joined. 

bleeder's joint. 

Hemophilia is not a constitutional disease but a condition inher- 
ited among the males of a family of bleeders, people who readily 
bleed subcutaneously or from slight wounds, and whose bleeding 
is difficult to stop. 

No cause of the bleeder's diathesis has been found. 

It has been traced to the seventh generation and the daughter of 
a bleeder, though healthy and without bleeding diathesis herself, 
may transmit the predisposition to her male offspring. 

Hemorrhages may occur in a joint or outside of the capsule 
of a joint and in some instances these are followed by fibrous anky- 
losis as if from a true inflammation of the synovial cavity. 

Absorption of blood clot takes place slowly; fibrin acts as a foreign 
body, irritates the joint and as a result there is often a chronic vil- 
lous hypertrophy of the synovial membrane, thickening of the cap- 
sule, and erosions of the cartilages; about the periphery of the joint 
exostoses form or else the bone and cartilage atrophy and these con- 
ditions may lead in time to true bony ankylosis. All of these con- 
ditions minus the blood are found in arthritis deformans. Atrophy 



CHAPTER XIII. 

TRUE INFLAMMATIONS OF BONES AND JOINTS— ACUTE 
AND SUB-ACUTE. 

PERIOSTEUM. BONES. 

True periostitis is due to an infection by pyogenic or pathologic 
micro-organisms; it accompanies infection of the bone and marrow, 
osteomyelitis, and is said never to occur without some slight super- 
ficial osteomyelitis. Suppuration may strip the periosteum from 
the whole shaft and be very destructive as in the following case. 

E. C, a hardy boy five years old, came under the writer's care at 
the Children's Hospital after four days of intense pain in his left 
leg. His temperature was 102.4; motion at the knee and ankle 
extremely painful; the whole leg (Edematous, hot, and the skin shiny 
with pink streaks in it; for three days I failed to determine exactly 
where the suppurative process was, and then made an exploratory 
incision over the tibia only to find it healthy; some brawny resistance 
was then felt deep in the calf of the leg slightly to the outer side, and 
an incision on the outer side of the leg soon opened the distended 
periosteum of the fibula; the shaft was floating about loose, the per- 
iosteum had not yet broken through but was gangrenous in two spots 
near the junction of the upper and middle third; the shaft was divi- 
ded and removed and after free irrigations sutured the periosteal 
wound leaving the extremities open for drainage. The patient 
soon developed scarlet fever and went to the contagious ward under 
the care of Dr. Legg, who in the course of the fever, drained two small 
pockets of pus. In spite of this, the periosteum secreted a fairly 
strong bone throughout, except at the two points that were gan- 
grenous, and the child has full use of his leg. 

Nichols advises for suppurative periostitis with necrosis of the whole 
shaft that the abscess be drained and left five or six weeks before 
removing the sequestrum so that the periosteum may become healthy 

188 



TRUE INFLAMMATIONS OF BONES AND JOINTS. 189 

and begin bone-forming, as the wound can then be cleaned after 
removing the sequestrum. All cases of suppurative periostitis 
are not extensive and one often finds small areas of superficial osteo- 
myelitis beneath localized suppurating periostitis which subside 
readily when drained. 

Among the micro-organisms which cause suppurative periostitis, 
should be mentioned the ray fungus. 

Chronic Periostitis. — Chronic irritation of the periosteum with 
proliferation of the inner layer of cells, producing local new forma- 
tion of bone, may occur after blows, contusions, occasionally after 
abscesses of neighboring tissues and most frequently in the course 
of certain infectious diseases like syphilis; and a sort of general 
periosteal thickening involving most of the bones of the body has 
been described as a separate disease, toxic osteo-periostitis ossificans. 
The symptoms of periostitis, which is really a manifestation of 
periosteal reaction under an irritant, are constant dull pain over the 
point of thickening, with occasional exacerbations; sometimes, how- 
ever, there are no symptoms; the condition may be recognized first 
in a radiograph. 

Chronic periostitis demands no special treatment but one should 
treat its cause. 

Actinomycosis. — The ray-fungus, described by Hahn, in 1870, 
in a cow's tongue, was shown by Ballinger, in 1877, to be the char- 
acteristic organism of the disease of cattle known as lump jaw. 
Ponfick, in 1882, found similar lesions in human beings. The organ- 
ism may get in through the mouth, the throat, or gastrointes- 
tinal canal; growing at first locally, it extends to soft tissues and 
bones and after a time through the blood system, produces metas- 
tases which are like little abscesses. Like tuberculosis, a focus 
may begin in the marrow of the bone, causing softening and de- 
struction of the trabecular of the bones, but more often it produces 
little abscesses under the periosteum, particularly of the jaw, the ribs, 
and upper spine. The infecting organism may be detected in the 
purulent discharge of sinuses by finding minute yellow points in the 
fluid which, under the miscroscope, show the structure of the ray- 
fungus. It attacks children and men but is rare hereabouts. In 



IQO 



ORTHOPEDIC SURGERY. 



Bradford's case, where the cervical spine was involved, the skin of 
the neck and shoulders was riddled with sinuses, but improvement 
and cure followed the administration of iodide of potassium, which 
has been considered a specific, like quinine for malaria. 

Osteomyelitis means an infection of bone and bone marrow by 
pyogenic or pathogenic organisms. Staphylococcus aureus, citreus, 
streptococcus pyogenes, pneumococcus, typhoid bacillus, and other 





Fig. 100. — Abscess from osteo T 
myelitis of femur. Drawn from 
photograph. 



Fig. ioi. — Os- 
teomyelitis of the 
tibia, from photo- 
graph. 



organisms have been found in pure culture in bone marrow. Of 
these, staphylococcus is the one commonly found. 

Osteomyelitis generally comes in the shaft of the long bones near 
the epiphyseal line, while tuberculosis generally begins in the epiph- 
ysis. Some cases of osteomyelitis in the epiphysis may simulate 
acute tuberculosis; but acute epiphysitis or acute arthritis of infants 
is always pyogenic, not tuberculous. Mixed infections are 



TRUE INFLAMMATIONS OF BONES AND JOINTS. 191 

common; any bone may be attacked, but the femur, tibia, and 
humerus and phalanges predominate. It has been produced exper- 
imentally in animals. 

Although it may come at any age, about one-half of all cases occur 
between 13 and 17; three boys have it to one girl. Fatigue or ex- 
posure to cold and wet are sometimes invoked as causes and it not 
infrequently follows the exanthemata, usually as a secondary infec- 
tion of pyogenic organisms. Before the days of asepsis, it arose from 
sepsis in compound fractures and was often fatal. It is often sec- 
ondary to furuncle, carbuncle, phlegmonous inflammation, etc. 

The process starting in the marrow of the cancellous spaces usu- 
ally spreads extensively before piercing the dense cortex of the bone. 
In the shaft, after piercing the cortex, it lifts the periosteum, strips 
it and may separate it from the entire bone, causing necrosis of the 
entire shaft; or, it may pierce the periosteum, penetrate into inter- 
muscular spaces, and eventually point in the skin. From the epiph- 
ysis it breaks into the joint, causing havoc and destruction and some- 
times dislocating it; or the epiphysis may be separated from the 
shaft. These are extreme cases. 

Frequently localized osteomyelitis is less violent, necrosis is more 
limited, and small sequestra are formed to be slowly cast off. Ab- 
scesses bursting externally leave sinuses connecting with areas of 
dying or dead bone, which will eventually be cast off after being 
surrounded by an involucrum; the process is slow. Deformities 
arise from extensive bone destruction, from epiphyseal separation, 
or from pathologic dislocation produced by distention of the joint 
with pus. The risk of systemic septic infection, always imminent, 
becomes less after sufficient time has allowed the inflammation to 
be walled off by granulations. 

Symptoms. — The affection begins suddenly with fever, with 
chills or vomiting, with great pain in the affected bone or limb, and 
usually with stiffness of one or two neighboring joints. If the in- 
fecting organism be less virulent, the onset is more gradual and the 
symptoms are the same only more moderate. Swelling and tender- 
ness are first noticed; not infrequently, there is reddening and in- 
creased surface heat. The patient is pale, has a "septic look " the 



192 ORTHOPEDIC SURGERY. 

white blood cells are markedly increased. The radiograph is a valu- 
able aid in diagnosis. The initial stage of the severe type of the af- 
fection may, resemble typhoid fever; but post-typhoid osteomyelitis is 
not seen before the fourth week of that fever. Mild cases are often 
miscalled rheumatism, and sometimes the resemblance to tubercu- 
lous joint disease is very close. These can only be differentiated 
by repeated careful examinations and radiographs. It is to be 
hoped that the examination of the opsonic index of the blood for 
different forms of bacteria may aid in establishing a correct diagno- 
sis. 

Treatment. — The treatment is essentially surgical. It should 
be prompt and thorough. If it were possible to remove or even to 
drain suppurating foci within a day of the start, months of treatment 
would be saved. Usually before the surgeon is consulted the de- 
struction from suppurative inflammation has extended over a large 
part of the shaft, has caused the separation of an epiphysis, or 
produced dislocation just because it had been considered rheumatism. 
The surgeon should not fear, if he knows he has before him a well 
localized focus of disease, to attack and remove it early. But if 
inflammation has already extended to a large part of the bone, he 
should content himself with draining the bone by removing part of 
the cortex and drilling through the infected spongy portion. This 
relieves pain and affords an outlet for pus. Loosened seques- 
tra demonstrated by the probe or X-ray may be removed by opera- 
tion, leaving drainage. The process may end there, for the condi- 
tions after removing small sequestra are ripe for repair. In a later 
stage, when a large sequestrum is surrounded by a firm involucrum 
of hard bone, repair does not occur and sinuses persist for a life- 
time. This condition is called a chronic osteomyelitis with in- 
volucrum. 

Nichols advises for this the removal of both involucrum and 
sequestrum by a sub-periosteal excision, stitching and folding the 
sides of the periosteum tightly together so that the new bone form- 
ing from it will grow as a solid shaft and not as a thin tube. In the 
forearm or the leg below the knee, there are two bones and one acts 
as a splint for the other during the process of regeneration of bone; 



TRUE INFLAMMATIONS OF BONES AND JOINTS. 



193 



but in the thigh or upper arm, great shortening would occur if com- 
plete sub-periosteal removal were attemped, and Nichols recommends 
here to leave a strip of bone in the deepest part of the wound, stitch- 
ing the periosteum down on to it; the sutures should be absorbable 
catgut. 

Frequently after operating for osteomyelitis a cavity is left in the 




Fig. 102. — Chronic osteomyelitis and involucrum of the upper part of 
femur. {Children'' s Hospital, A. W. George, Radiographer.) 



bone to drain and drain; this unsatisfactory condition has driven 
surgeons to devise a number of ingenious methods of treatment. 
One of the most promising is that of Mosetig-Moorhof and con- 
sists in filling the cavity as a dentist does a tooth, and suturing the 
periosteum and skin over it. The filling is a mixture of four parts 
13 



194 ORTHOPEDIC SURGERY. 

of iodoform in three parts each of paraffine and oil sessame; the mix- 
ture is fluid at 113 Fahr., but the iodoform has to be kept in sus- 
pension by stirring just before it is poured into the cavity which is 
previously made aspetic and dried of all trace of moisture. 

Epiphysitis and a pus joint are not uncommon in babies and 
will be described under the title of "Arthritis of Infants" (page 
197). Clinically one sees a sudden sepsis, high fever and vomiting, 
with great pain and tenderness made worse on attempting to move; 
soon an abscess appears and surgical aid should be immediate to 
prevent further destruction. The knee, elbow or hip is usually 
selected. Osteomyelitis of the spine is probably not a common 
affection; the infection here may be of a mild type, may simulate 
tuberculosis. 

Osteomyelitis of the Spine. — The following case is an example : 

A child of eleven months was seen by the writer in consultation 
with Dr. Chandler, of Medford. There was an abscess in the left 
loin and a history of ten days of fever, vomiting and crying. After 
incision, the finger penetrated beyond the transverse process of the 
third lumbar vertebra and removed from the side of the body a loose 
sequestrum of cancellous bone almost globular, half an inch in di- 
ameter. The cavity was irrigated with sterile water, a. small gauze 
wick was inserted and a sterilized dressing applied. After three 
days, suppuration had ceased; the wick was removed little by little; 
the wound healed in two weeks, and a celluloid jacket allowed the 
patient to be carried around in an upright position. At the end of 
six months, the back was as flexible as that of any child, and all 
further treatment was discarded. No deformity or subsequent 
stiffness resulted. 

Abscess from osteomyelitis of the spine may be less easy to reach. 
Paralysis may be a symptom as it is in tuberculous vertebral disease, 
due to pressure of pus on the cord. 

Osteomyelitis near the Hip. — Acute osteomyelitis is less common 
in the region of the hip than in the lower end of the femur; it attacks 
the upper part of the shaft and rarely the epiphysis and it occasion- 
ally comes on the pelvic side. When the upper juxta-epiphy- 
seal part of the femoral shaft is attacked, separation of the epiphysis 



TRUE INFLAMMATIONS OF BONES AND JOINTS. 195 

takes place; in some joint suppuration and ankylosis may result 
from it or spontaneous luxation of the hip. Diagnosis is made from 
the very acute symptoms which characterize osteomyelitic affections 
in little children and infants. 

A chronic osteomyelitis near the hip is not at all rare, according 
to Koenig, at whose clinic many hips were excised and carefully 
examined with reference to this point; it was the real cause of one 
case in seven or eight of those excised for hip disease. The process 
is sub-acute, less destructive, and much slower than the acute arthri- 
tis of infancy, and resembles closely tuberculous hip disease. We 
are often unable to differentiate these forms, but there exist many 
cases of hip disease with atypical symptoms, in some of which a 
careful radiographic study, and the determination of the opsonic 
index of resistance to different forms of infective organisms, enable 
us to differentiate. Cases of hip disease with severe symptoms, 
acute onset of high fever, leucocytosis, and delirium, however, should 
always arouse suspicion of either osteomyelitis, or of tuberculous 
meningitis. 

Osteomyelitis following Typhoid Fever. — This occurs not infre- 
quently. The lesions are usually small and superficial, an osteo- 
periostitis — extensive destruction of bone marrow only occurs when 
there is a secondary infection with pyogenic organisms. It usually 
comes on late in cases of typhoid fever or during convalescence, as 
does typhoidal arthritis. Keen tabulated the period of onset in 
typhoid as follows: before the third week 16 cases, from third to sixth 
week 66, later on 104 cases. The bones affected were chiefly the 
femur, tibia, and ribs; but it may attack any bone. Pure cultures of 
typhoid bacilli are sometimes found even in the old sinuses. 

Osteomyelitis following measles, the other exanthemata, and 
zymotic diseases like pneumonia is not very rare and will be con- 
sidered with arthritis on page 199. 

TRUE INFLAMMATION OF JOINTS— ACUTE. 

Septic Arthritis. — Inflammation of the joints from septic infec- 
tion or after acute infectious disease may be mild or severe, the 
fluid in the joint may be serum or pus, and the course of the affec- 



196 ORTHOPEDIC SURGERY. 

tion be acute or chronic. Sometimes micro-organisms are in the 
fluid and at other times only their toxins, as though they had never 
been there or had died out; the infecting organism may be one 
peculiar to a general disease, or be any pyogenic organism, or 
both may be mixed. The original infection may be traced to a 
scratch of the skin or of the mucous membrane, or it may be second- 
ary to some septic process, a furuncle, carbuncle, cellulitis, erysipelas, 
abscess, or it may come in the train of infectious diseases like cere- 
brospinal meningitis, diphtheria, dysentery, glanders, gonorrhoea, 
influenza, measles, mumps, pertussis, pneumonia, puerperal fever, 
scarlet fever, tonsillitis, typhoid fever and probably others; like 

other septic processes it may 
often be impossible to deter- 
mine the entrance point of in- 
fection. 

Any age may have it, one or 
several joints may be involved. 
The process in the joint may 
be very mild, almost like sub- 
Fig. 103.— Suppuration in knee joint acute traumatic synovitis only 

with osteomyelitis of lower end of femur. 

Traced from photograph. the capsule is swollen as well 

as distended with effusion 
which absorbs slowly and ends in perfect recovery, or the fluid may 
contain some fibrin which does not absorb, or there may be a 
growth of villi from the lining membrane of the joint which may 
change into fat or cartilage and the condition be a chronic villous 
arthritis; or with the swelling of the membranes a pannus may 
form and the articular cartilage become fibrillated and in time dis- 
appear beneath it; or else the process may be from the start a sup- 
puration of the whole joint. One joint alone may be involved, or 
within a few weeks several may be affected, when, as a rule, fur- 
ther joint troubles stop appearing in new places. 

Symptoms. — On account of the variety of infecting organisms 
and the well-known difference in virulence at different times of the 
same bacterium, there is the widest range of symptoms. What 
symptoms are common to infections of joints may be summed up 




TRUE INFLAMMATIONS OF BONES AND JOINTS. IQ7 

as follows: Sudden onset of local pain, tenderness to pressure over the 
joint with impaired function, stiffness and spasm, and if in a super- 
ficial joint the other cardinal symptoms of joint inflammation, swel- 
ling and increased heat of the surrounding skin are present; 
and the constitutional symptoms of fever, increased pulse rate, and 
an increased number of white blood corpuscles, a leucocytosis at 
first without appreciable fall in hemoglobin. Some lymph nodes 
usually enlarge and remain so during the period of infection. The 
history of recent diseases should be heeded and a careful, thorough 
examination of the whole body be made for a possible entrance of 
infection. Mild symptoms indicate inflammation without sup- 
puration; early symptoms of a pus joint are the same only much 
exaggerated, often there is evidence of extensive destruction and of 
abscess. Late in non-suppurative and more chronic cases infiltra- 
tions in the peri-articular tissues and thickening of the capsule are 
added to the early signs of the process and a secondary anaemia de- 
velop;, which is known by the decrease in hemoglobin index. 

But little headway has been made in differentiating by the clinical 
symptoms between the different forms of infections due to definite 
micro-organisms. 

Rheumatic Fever. — Rheumatic fever, if one accepts the Micro- 
coccus rheumaticus as its sole cause, may be differentiated from the 
rest by the absence of suppuration, although the signs of inflamma- 
tion may indicate it, and a progressive and successive involvement of 
joint after joint; and also by its proclivity to excite endocardial and 
pericardial inflammations with or without joint trouble; the cause 
of rheumatic fever is still sub judice. 

Acute arthritis of infancy is a septic infection with definite 
symptoms and course and it has been considered a separate disease, 
but one knows that it is caused either by a primary septic arthritis 
or a primary epiphysitis (osteomyelitis of the epiphysis) breaking 
into the joint and that the inflammation is produced by the presence 
of ordinary pyogenic organisms. The following case of acute infan- 
tile arthritis of the hip will illustrate what the affection may be. 

J. C. entered the Infants' Hospital, aged 14 months. For 
three days he had vomited, had high fever, and cried out 



190 ORTHOPEDIC SURGERY. 

whenever he was moved. The patient's left thigh was much 
swollen and fluctuating from the crest of the ilium to the knee 
A firm resistant mass could be felt in the iliac fossa near 
the pelvic brim. He had high fever and was evidently very sick. 
A free opening from the crest of the ilium two-thirds of the dis- 
tance to the knee let out a large quantity of pus, the abscess cavity 
extended over the pubic bone into the pelvis; in it the dislocated 
femoral head lay on the dorsum ilii, there were rough edges of bone 
in the acetabulum and it was perforated; the head was put in but 
slipped out at the first dressing and two attempts at reduction in the 
next week were unsuccessful. Five months later I replaced it by 
the open method, scooping out and enlarging the acetabulum and 
removing an exostosis from the neck of the femur which overlapped 
part of the head. The result was a useful straight hip with only 30° 
of motion. 

The treatment of all acute septic infection of the joints with sup- 
puration is the same as that of infantile arthritis. The earlier 
surgical intervention is obtained the better; all should be opened by 
a free incision under complete anaesthesia, preceded in doubtful cases 
by aspiration for diagnosis, and the cavity irrigated and drained 
while suppuration lasts. Pyogenic infections of the joints vary in 
virulence, but it is always safer to drain than not to. 

ARTHRITIS IN ZYMOTIC DISEASES. 

Infectious arthritis and infectious osteomyelitis are often so mixed 
that they cannot be distinguished clinically. Measles, typhoid 
fever, scarlet fever, pneumonia, mumps, diphtheria, in fact any 
zymotic disease in which other infections like otitis media have been 
known to occur, may be attended with osteomyelitis or joint inflam- 
mation during the course of the disease or soon after. 

Typhoid Fever. — Joint disease following typhoid fever has been 
carefully studied by Dr. W. W. Keen, of Philadelphia, in a book on 
the Surgical Complications of Typhoid Fever. 

He found three types of joint affections in typhoid fever, which he 
called the rheumatic, the septic, and the typhoid. Of the latter he had 
records of 142 joints; the affection was both monarticular and polyartic- 



TRUE INFLAMMATIONS OF BONES AND JOINTS. 199 

ular; suppuration was not common and was sometimes followed by ne- 
croisis and a sinus; the joints affected were the hip, ankle, elbow, shoul- 
der and knee. Generally the outcome was a return to a useful joint 
with some impairment of motion unless they dislocated; but out of 
84 patients 43 had a dislocation, and of these 40 were hips, two 
shoulders and but one knee. 

In the spine a definite condition has been described called typhoid 
spine; first it was considered to be a neurosis or "perispondylitis" 
it is generally regarded to-day as a destructive osteomyelitis and 
arthritis of the spine, for at times vertebral bodies are damaged 
like the deformity from Pott's disease. Cases generally develop 
a week or more after the subsidence of fever during the first 
days that a patient is up. There is a gradual increase of the 
pain in the back which becomes agonizing, and which pre- 
vents the slightest motion even in bed and is with difficulty con- 
trolled by morphine. 

Hyperextension of the spine in a plaster bed or by a plaster jacket 
affords relief but does not entirely stop the pain which may last 
two months or more. Both a small knuckle and the prominence of 
five or six adjoining vertebrae have been noticed and radiographs 
have demonstrated an abscess about the vertebrae. Some cases 
recover without deformity, some with a slight knuckle, others with 
rigidity of the lumbar spine where the seat of the affection is oftenest 
found. 

Porter, of Chicago, reported a case of typhoid coxitis, with skia- 
grams. The arthritis was ushered in by a chill five weeks after the 
beginning of typhoid fever with pain in the left thigh and hip, flexion 
of the thigh, tenderness to pressure, and, near the trochanter, a red 
spot appeared which discharged thin, yellowish pus. One month 
later, the other hip was affected similarly and dislocation occurred 
in the second hip, which was reduced afterward but allowed limited 
motion, apparently because both acetabulum and femoral head had 
been largely destroyed. 

Pneumonia. — Joint disease in the course of pneumonia occurs 
infrequently. It may come on gradually during latter part of the 
disease or during convalescence. Joint infections of the diplococcus 



200 ORTHOPEDIC SURGERY. 

of pneumonia, however, frequently occur in children without pul- 
monary pneumonia, the infection arising from the throat, nose, or 
ear generally. 

Cave collected 31 cases of pneumococcus joints including one of 
his own; the pain and swelling were limited to a single joint with con- 
siderable oedema of the whole neighborhood and redness. There 
was sometimes abnormal mobility from destruction of ligaments and 
grating from destruction of cartilage. Recovery was slow and the 
joint ultimately stiff. A diagnosis should only be made from a 
pathological or cultural examination of the fluid. Healing takes 
place rapidly after the joint has been thoroughly opened, complete 
recovery of function may be expected if the suppuration has only 
been of short duration. 

Non-tuberculous infections of the bone marrow and joints may 
be chronic as well as acute and those following pneumonia form no 
exception to this rule. 

Gonorrhoeal Arthritis. — Gonorrhceal arthritis or gonorrhceal rheu- 
matism accompanies from 2 to 3 percent of gonorrhoeas; it appears 
in the later stages; one joint may be affected or several. The knee 
is the commonest, but the ankle, wrist, fingers, elbow, shoulder, hip, 
jaw, — in fact any joint may be attacked. The affection is always 
painful and generally slow. The swollen joint is at first uncomfort- 
able later very painful, and is both stiff and weak. When the symp- 
toms are acute there is much joint pain, local heat, thickening of 
the tissues and muscular spasm, and in very severe cases a pus joint. 
The gonococci may be in the fluid, in the pus cells of the granula- 
tion tissue, or growing beneath the synovial membrane. Mixed 
infections may be found, or at times no micro-organism at all, because 
they have died out. Thickening from infiltration of the capsule is 
always present and the joints may be cedematous, with the skin hot, 
sensitive and inflamed; ankylosis is a frequent result. The effusion 
may be serous, sero-fibrinous, or purulent. The sero-fibrinous var- 
iety is the commonest; fibrin deposited upon the folds of the syno- 
vial membrane may become organized by a growth of vessels from 
the synovial membrane forming a pannus; the cartilage under it is 
fibrillated, eroded, ulcerated, or disappears; the fibrin coating the 



■^^"" 



TRUE INFLAMMATIONS OF BONES AND JOINTS. 201 

folds of synovial membrane makes them adhere together; the liga- 
ments may also be involved in adhesive inflammation and the sur- 
rounding bursas and tendons. 

Villi grow from the synovial membrane in abundance. In the 
late stages, the swelling and pain may continue, motion is 
limited or lost, and the joint fixed in a position of deformity. 
Some consider any obstinate painful swelling of a single joint 
suggestive of gonorrhceal arthritis although gonorrhoea is a poly- 
articular affection as often as not. In the chronic cases gonococci 
are absent, in acute they are usually present. 

The following clinical forms have been described: arthralgia 
without definite lesion, or with very slight peri-arthritis or bursitis; 
acute synovitis, resembling 
rheumatism because peri- 
articular structures are swol- 
len and the joint distended; 
peri-arthritis without effusion 
in the joint; tenosynovitis, 
around a joint which may or 
may not be inflamed; purulent Fig. 104. — Gonorrhceal arthritis with 
synovitis; chronic synovitis subluxation. 

with the formation of quantities of granulation tissue, or with a sero- 
fibrinous exudate and a pannus and ending in true ankylosis or in 
fibrous ankylosis. 

Treatment in the acute stage should include the urethra if there 
be any evidence of gleet or stricture. The joint should, have rest 
in the acute stage, or rest and compression, and if there be much 
fluid it should be withdrawn by aspiration, an examination made 
for gonococci, and if it be sero-pus or pus, it should be drained. 

Obstinate cases demand protection from weight-bearing by appa- 
ratus, or fixation in a plaster bandage. Rebellious cases should 
be incised and washed out with hot sterile water or weak corrosive, 
and drainage for a week with repeated irrigations has done good 
Villi should be excised. 

Ohlmacher, and others report excellent results in cases of 
gonorrhoea] rheumatism treated by the method of Wright and Doug- 




202 ORTHOPEDIC SURGERY. 

las, by the subcutaneous injection of an emulsion of the dead bodies 
of gonococci. In one patient the arthritis had lasted four months 
and in the other four years and many joints were involved. 

There is the prospect of the same good results in other forms of 
joint infections provided that the organism may be recovered from 
the joint and grown so that the patient may be inoculated with an 
emulsion of the dead bodies of the bacteria of his own disease. 

Bier's passive hyperemia treatment has given excellent results 
in the hands of many, even in long standing, exquisitely tender, sen- 
sitive joints. Several turns of rubber bandage are fastened around 
the limb above the joint tight enough to constrict and redden but 
not to make the limb blue, cold or to give pain. It is worn from 2 
to 22 hours out of the 24. As soon as the pain stops, usually in an 
hour or two after application, the joint should be gently moved to 
prevent stiffness 



CHAPTER XIV. 

CHRONIC INFLAMMATION OF THE BONES AND JOINTS 
—SYPHILIS AND TUBERCULOSIS. 

In the more chronic forms of inflammations of the bones and joints, 
tuberculosis and syphilis, there usually is present both an inflammation 
of the bone and an inflammation of the joint. Tuberculosis of the 
synovial membrane doubtless exists as a primary inflammation, 
but it is rare post-mortem. Careful study of pathologic material 
shows the synovial cavity was attacked more recently than the bone. 
Syphilis may attack a joint independent of bone disease, but this 
is rare, coming as a synovial serous effusion, or in infants as an acute 
joint suppuration, but hereditary syphilis is always associated with a 
peculiar change around the epiphyseal disc, while in acquired syphilis, 
periostitis or periosteal nodes from previous periostitis are present; 
or, dense ostitis or eburnation of the long bones may be asso- 
ciated. These processes are not dissimilar from the standpoint of 
pathology, and form a natural group of chronic infectious inflam- 
mations of bones and joints, whose chief point of difference lies in 
the behavior of the periosteum. In tuberculosis its proliferation 
is not increased and we have marked bone atrophy; in syphilis the 
periosteum proliferates, thickens and either makes nodes on the 
shafts of the bones, or the endosteum fills them with dense bone 
like ivory. 

SYPHILIS OF THE BONES AND JOINTS. 

Infantile Syphilis. — Parrot calls infantile joint disease of heredi- 
tary syphilis an osteochondritis. There is a broadening and an 
irregularity in the cartilaginous epiphyseal line with enlargement 
of the epiphysis and little irregular growths from the cartilaginous 
layer onto the shaft. Separation of the epiphysis may occur, syno- 
vitis accompanies it; it is less often serous than purulent. In in- 

203 



204 



ORTHOPEDIC SURGERY. 



fancy joint suppuration occurs, articular cartilages are eroded and 

the joint may be destroyed. 

Under constitutional treat- 
ment the effusion may be ab- 
sorbed unless suppuration has 
already begun to take place. 
Shortening in older children 
depends on how much damage 
is done to the epiphyseal car- 
tilage. Separation of the epi- 
physis is sometimes seen with- 
out any sign of inflammation, 
and the limb hangs useless, 
flail-like, and apparently par- 
alyzed, the syphilitic pseudc- 
paralysis of the newborn, of 
Parrot. Pain and tenderness 
in syphilitic bones are gener- 
ally due to periostitis. 

Syphilis in Childhood. — 
The metacarpal bones and 
phalanges are sometimes at- 
tacked by syphilitic dactylitis. 
A slow enlargement and 
widening occurs, abscess forms 
slowly and eventually may 
lead to the disappearance of 
a phalanx or a large part of a 
metacarpal bone when un- 
treated. In rare cases, crani- 
otabes may be found. Both 
syphilitic periostitis and the 
typical irregular contours of 
the juxta-epiphyseal region 

may be demonstrated by the X-ray negatives. 

As both syphilis and rickets distort the juxta-epiphyseal region in 




Fig. 105. — Syphilitic eburnation and 
periostitis. {A. W. George, Radiographer.) 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 205 

little children, the conditions may be confounded with each other. 
Rotch says that syphilitic bones do not present the spongy bone 
enlargements peculiar to rhachitis, and rhachitic bones never show 
the osteophytes of syphilis; a thick dense shaft from hereditary syph- 
ilis appearing in middle childhood means overgrowth of the cor- 
tex of the bone. The syphilitic joint is distinguished from tuber- 
culosis by absence of spasm, but atrophy of the limb is marked; 
swelling, slight tenderness and some heat are present. 

Syphilitic bone disease marked by overgrowth of bone, attacks 
the long bones of the lower leg and forearm chiefly ; the growth comes 
from both periosteum and endosteum, the shafts are thick and the 
bone hard as ivory. The process usually comes under treatment 
en account of the so-called rheumatic pains in the legs of children 
who are approaching puberty. The tibia and fibula are usually 
affected and may show a marked bowing forward. The tibia is 
usually bowed forward and feels more or less round like a broom 
handle, — in fact it is not very dissimilar to the tibia of ostitis defor- 
mans. The bone is eburnated, heavier than normal, and offers much 
greater resistance to penetration of the X-ray. Though it is sometimes 
moderately tender to pressure, it has nothing like the extreme tender- 
ness of osteo myelitic bone. In older children syphilitic joint disease 
is a serous synovitis which may be very rebellious to treatment. 

Pathology. — The irregularity of the line between the epiphysis 
and shaft observed in rickets is exaggerated in a syphilitic bone, 
and has been described as a toothed tine instead of a straight line 
across the bone. This irregularity is due to unequal activity in 
ossification; some parts of the epiphyseal cartilage proliferate, 
become provisionally calcified and turn into true bone in a normal 
manner, while neighboring portions remain cartilaginous, keep 
on proliferating, and grow far out into the shaft. Sometimes 
one finds great enlargement and thickening of the whole epi- 
physis; at other times, the proliferation of the forming layer of the 
periosteum may thicken the shaft in circumscribed areas, produc- 
ing lumps on the bone; such are the so-called nodes of the tibia; 
similar activity of the endosteum causes a deposit of bone on the 
interior of the shaft which may largely or entirely obliterate the 



2o6 ORTHOPEDIC SURGERY. 

canal of bone marrow. Thickening and proliferation of the 
periosteum and endosteum in the shafts of the long bones are read- 
ily demonstrated by means of the X-rays. 

Gummata may form in the cancellous tissue and in the lower 
layers of the periosteum of the shaft or the epiphysis. According to 
Nichols, when a gumma occurs in the spongy bone of an epiphysis 
near a joint, secondary changes develop in it giving rise to a con- 
dition which cannot be distinguished clinically from tubercu- 
losis of the joint or chronic arthritis. The periosteum may be affected 
by a gummatous growth, especially the sternum, collar bone, and 
skull, and sometimes large sequestra are found beneath them. A 
gumma in the marrow of the metacarpals or the phalanges is the 
sole cause of syphilitic dactylitis. A whole phalanx may be ne- 
crosed and the necrosis be attended with proliferation from the peri- 
osteum forming an involucrum or spina ventosa. 

Diagnosis. — The diagnosis is made on the presence of other phys- 
ical signs of syphilis together with a history of it. The signs of 
syphilis in infancy are snuffles within two or three weeks of birth, 
papular and pustular eruptions involving the palms and soles com- 
ing on usually within two or three months; the eruptions may con- 
sist of macules, papules, pustules, or bullae, according to the mild- 
ness or severity of the infection, or there maybe an eruption resemb- 
ling psoriasis or the so-called "rupia crusts." Enlarged lymph 
nodes are not characteristic of hereditary syphilis. The nails 
are frequently affected, a papule or pustule appearing on the skin 
at the side of the nail, which ulcerates and causes loss of the nail. 
The first dentition is delayed, the primary teeth decay early; the 
second teeth may have the characteristic appearance figured by 
Hutchinson. Stomatitis, fissures, ulcers, and mucous patches may 
be present in the mouth; and condylomata about the anus. 

The osteochondritis of syphilis presents itself clinically as a swell- 
ing at the junction of the shaft and epiphysis, of long bones, or 
as small, local, round swellings, the tumor rises abruptly from the 
bone; it may be small and globular or may form a ring where the 
shaft and epiphysis join or . the w T hole epiphysis may be enlarged. 
The enlargement of the whole epiphysis occurs in adults only. 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 207 

Treatment. — Infant cases should be treated by mercury. Late 
cases with iodide of potash or with mixed treatment. Inunction is 
effectual in infants; blue ointment, diluted with an equal amount 
of lanoline may be applied to a thin flannel band which is left in 
place for forty-eight hours, or one grain of gray powder may 
be given three times a day. When destruction of the joints has oc- 
curred, drainage, removal of sequestra, and other surgical indica- 
tions, must be met by appropriate operation. 

Syphilitic Spine. — Many cases of hunch back reported in syphilitic 
individuals fail to show whether the knuckle be due to tuber- 
culosis or syphilis. Gummata in or near the vertebrae have been 
observed at autopsy and also vertebral exostoses of supposedly syphil- 
itic origin. A few cases have been reported, however, where deform- 
ity was present and disappeared under syphilitic treatment. 

Such a case is reported by Joachimsthal as spondylitis gummosa. 

The patient, 54 years old, had suffered for a year from stiff- 
back, and finally had complete inability to lift his head which 
was flexed on his breast. In walking and standing he supported 
his chin with both hands. The vertebra prominans was the apex 
of a kyphos, the angle of which was 45 . His pain was referred to 
the deformity, also to the lower back which was much hollowed, 
and walking brought on rigidity of the spine and chest. There was 
a history of chancre two years before. Mixed treatment produced 
rapid improvement, both the pain and the deformity disappeared. 
Joachimsthal believes this an isolated observation. 

TUBERCULOSIS OF THE BONES AND JOINTS. 

CARIES OF THE SPINE. 

Synonyms. — Pott's disease; vertebral tuberculosis; angular cur- 
vature; posterior curvature; antero-posterior curvature; spondyli- 
tis; in German, Spondylitis tuberculosa; Spondylarthritis tubercu- 
losa; Wirbeltuberkulose; Pott'sche kyphose; Spitzbuckel; in French, 
Mai de Pott; Mai vertebral; Cyphose; Gibbosite; in Italian, Ciph- 
osi: Morbo di Pott. 



208 



ORTHOPEDIC SURGERY. 



This is a tuberculous ostitis of one or more vertebra:, causing 
a collapse of their bodies hence the formation of an angular 
hump of the spinal column. The intervertebral discs are often 
destroyed by the process, but only in rare instances does tuberculo- 
sis affect any part of the arch of a vertebra. Remains of prehis- 
toric man show the deformity which attacks also domestic animals 
and wild ones in captivity. Hippocrates treated it in 400 B.C., and 
described different kinds of spinal curvatures. Percival Pott, in 
1779, defined it accurately; its tuberculous nature was demon- 
strated by Delpech and Nelaton, in 
1836. It is a common disease; about 
1 J percent of all autopsies in Germany 
and Austria show this deformity; more 
than one-fifth of all cases of tuberculous 
b^ne disease have their seat in the spine; 
it is slightly more common in boys than 
girls, and any part of the spine may be 
diseased. The frequency with which 
different regions are affected has been 
variously estimated by different ob- 
servers. Hereabouts, there is one cervi- 
cal for three dorsal or five lumbar cases; 
but in New York, out of 1000 cases, 6.6 
percent were cervical, 70.9 percent dor- 
sal, and 22.5 percent lumbar. A history 
of trauma is obtained in many cases; 
trauma may be the localizing cause but there must be exposure to 
tuberculosis, and a general physical condition incapable of resisting 
its invasion. 

Pathological Anatomy. — It is said to attack the vertebral column 
in two ways, — either on the surface of the bodies of the vertebrae, or 
in their interior; the former is rare. A focus of tuberculous ostitis 
is characterized by the same phenomena in the spine is in other bones. 
In the bone marrow of the cancellous interior of a vertebral body, 
granulomata form, anatomical tubercles, containing giant cells and 
tubercle bacilli, epithelioid cells and leucocytes; they multiply, absorb 




Fig. i 06. — Caries of spine : 
upper dorsal. (Children's 
Hospital.) 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. .209 



and soften the bone and undergo themselves a cheesy degeneration; 
they may surround healthy areas, cause necrosis of the surrounded 
bone, and form sequestra of varying size. Liquefaction of the 
cheesy detritus produces the so-called cold or tuberculous abscess, 
the walls of which are composed of granulomatous tuberculous 
tissue. These abscesses may be of large size after they break through 
the bone and infiltrate the soft 
parts, burrowing in the line of 
least resistance, guided by the 
fasciae and muscle sheaths; the 
bone of the vertebral body, 
weakened by tuberculous infil- 
tration, collapses under the 
body-weight, the intervertebral 
discs are attacked and easily 
destroyed; the size of the hump 
depends on the number of 
bodies affected; at the begin- 
ning, the hump is small, sharp, 
and angular; later on, more 
vertebrae are involved and it is 
rounded. When the tubercu- 
lous ostitis approaches the back 
of the vertebral body and the 
spinal canal, the swelling may 
press upon the cord through its 
meninges, producing paralysis, 
or it may press upon the nerve roots in the intervertebral foramina, 
producing referred pains, — pains referred to the terminals of the 
compressed nerves. A growth of anatomical tubercles has been seen 
in the meninges of the cord but not in the cord itself. In some 
instances the cord has been found flattened, compressed over a small 
area but other autopsies have shown no diminution in the size of the 
cord, but an edematous infiltration produced by the local inflam- 
mation pressing on the large lymph vessels and veins coming from 
the cord. Schmaus and Kahler believe that this oedema of the cord 
14 




Fig. 107. — Destruction of sixth and 
part of seventh dorsal. Age 2 years. 
(Infant's Hospital.) 



2IO ORTHOPEDIC SURGERY. 

is followed, if it persists long, by a cicatricial fibrous tissue, a 
sclerosis, which may make the paralysis permanent. Although great 
destruction of vertebral bodies may be present it is rare for the 
bones to cause pressure on the cord in Pott's disease. 

Symptoms. — These are the referred pains, which may mislead; 
night-cries, which are uncommon; and early paralysis or paresis, 
which is also unusual. The physician is, therefore, largely depen- 
dent on physical signs for his diagnosis. Peculiarities of attitude and 
gait often pass unnoticed by the parents and the deformity may also. 

Referred pains depend upon the distribution of the nerves which 
are pinched; in the cervical region, the pains are in the arms and 
shoulders; in the dorsal, one finds stomach-ache and girdle pains; 
in the lumbar, pains in the legs. 

Night-cries are uncommon in Pott's disease. The pains which 
cause them are characteristic of tuberculous bone disease. Chil- 
dren, after going to sleep, wake suddenly with a loud cry and either 
go to sleep again at once or remember no pain. Night-cries are very 
common in hip disease and fairly so in tuberculosis of the knee. 
They may come every night many times or only come once or 
twice a week; there is no regularity, but frequent night-cries indi- 
cate that the disease is increasing. 

Paralysis may come before deformity. It begins with weak legs 
increased knee-jerks and ankle clonus; but sensation is seldom 
affected. In all cases of paresis of the legs, of doubtful origin, one 
should think of Pott's disease and strip the child and examine his 
back, for even if no deformity has developed, vertebral disease may 
reveal itself by the stiffness of the back. 

Psoas contraction and its detection. When a spinal abscess com- 
mences to burrow into the psoas muscle, or even when its proxim- 
ity to the muscle irritates it, muscular rigidity or spasm appears 
in that muscle; as a result the psoas muscle is thrown into a con- 
dition of partial contraction, and the hip is either partly flexed or 
cannot hyperextend. If the hip is slightly flexed the knee turns out, 
and lameness results in seeking medical advice. 

Physical Signs. — Peculiarities of attitude and gait are usually 
conspicuous; the child walks stiffly to avoid jar, bears most of his 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 2 11 



weight on his toes, does not lift his feet high. The position of the 

body varies with the region affected; cervical disease may give rise 

to the position of wry neck, or the head may be thrown well back 

and to one side, or the chin drooped forward on the chest, where the 

hands frequently have to support it; in the cervico-dorsal and upper 

dorsal regions the shoulders are raised and squared. There is much 

more stiffness in dorsal caries and 

the deformity always shows early 

and affects the shape of both the 

back and the chest in a typical 

way. In the lumbar region the 

child sticks his stomach out " liks 

an alderman, " walks with head 

and shoulders thrown back. 

These attitudes and gaits are so 

typical, that one can locate the 

disease often in those who pass 

us on the street. The deformity 

appears early in the dorsal region 

and is here hardest to control. 

A very slight degree of deformity 

establishes the diagnosis at once 

but the student should learn to 

recognize Pott's disease before 

deformity occurs. The precursor 

of deformity is muscle spasm; all 

the peculiar attitudes and gaits 

we have noted are due to rigidity 

or spasm of the muscles of the 

back, as mav be seen if the child 




Fig. 108. — Cervical caries showing 
wry-neck position. (Children' s Hos- 
pital.) 



Iks 



ibout stripped, and is 
easily recognized as the movements of his spine are tested. 
Spasm may limit either forward bending, backward bending, side 
bending, or rotation, but it generally restricts backward bending 
most. If the child is asked to pick up an object from the floor, 
his muscle spasm is shown by the way he does it; muscular stiffness in 
the neck is tested by observing how he nods and extends the head, 



212 ORTHOPEDIC SURGERY. 

turns to the side, etc.; forward bending of the trunk and neck by 
asking him to sit on the table with the feet straight before him and 
grasp his toes; backward bending and side bending of the trunk by 
having him lie on the face while the observer, grasping the ankles, 
bends the knees, and slowly raises pelvis, when the normal sagging 
is lost; by carrying the ankles to the right or left, muscular resistance 
to side bending can be seen. 

Any examination of physical signs for suspected Pott's disease 
is incomplete without a search for the two common complications, ab- 
scess and paralysis. The back of the throat, sides of the neck, iliac 
fossae, loins, Scarpa's triangle in the thigh, and the region of the 
gluteal fold should be observed and palpated for swelling and deep 
resistance due to abscess. Psoas contraction produces a loss of 
hyperextension of the hip. Hyperextension of the hip is tested by 
having the child lie on his face on a table while the observer grasps 
his ankles and lifts each alternately to detect restriction of hip 
motion. Psoas contraction produces lameness partly compensated 
for by the child's walking on his toes. 

To test the knee-jerk and ankle clonus for early paralysis, 
one merely taps with the finger tips or the ulnar border of the 
extended hand the patellar tendon, as the knee hangs flexed during 
the test with the muscles relaxed; for the clonus the knee should 
be straight and the observer, grasping the foot in plantar flexion with 
the fingers under the ball of the foot, suddenly brings the foot into 
dorsal flexion and notes any succeeding contractions of the gastroc- 
nemius which occur. One should be familiar with the normal knee- 
jerk in order to appreciate if it is increased. 

Complications. The complications of Pott's disease are abscess 
and paralysis. 

Abscesses in Pott's disease are at the start tuberculous but may 
become infected later, — mixed infections. At first confined to the 
bone, they may break through it and become very large, dissecting 
a space for themselves wherever resistance between muscles and 
fasciae is least. The routes of pus-burrowing vary for different 
parts of the spine, but all abscesses do not travel far, — some remain 
small, cease to grow, become eventually encysted and calcareous 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 213 

or undergo resorption. In the upper half of the cervical region the 
space behind the pharynx is commonly invaded and a retro-pharyn- 
geal abscess bulges the posterior pharyngeal wall forward, interferes 
with deglutition and respiration, and makes the child carry its 
head in a peculiar, semiextended position. If the symptoms are 
not urgent the abscess may pass unrecognized until it invades 
the loose tissue in the neck and becomes superficial behind the angle 
of the jaw, where some prefer to attack it. Abscesses starting from 
any part of the cervical spine may displace the oesophagus, larynx, 
and trachea forward, invade the loose tissues within the deep cerv- 
ical fascia and present on the side of the neck ; they may also descend 
into the posterior mediastinal space, have even been known to dis- 
sect their way downward along the aorta, iliac vessels, and present 
in the front of thigh, — the longest course ever taken by an abscess. 
The Germans call cold abscesses, Senkungsabscessen. 

Abscess likewise from disease of the dorsal vertebrae may invade 
the posterior mediastinal space, where they give rise to attacks of 
dyspnoea from pressure on the recurrent laryngeal nerves. They 
seldom penetrate the abdominal or pericardial cavities but may 
follow the great vessels down to the iliac fossa, to Scarpa's triangle, 
to the anterior abdominal wall, scrotum or pelvis. They have 
been known to break into the bladder, rectum, or ischio-rectal fossa; 
they may also follow the sciatic nerve from the pelvis and present 
at the gluteal fold. 

In low dorsal disease pus often gets into the psoas muscle, travels 
within its sheath, pointing either in the iliac fossa, or in Scarpa's 
triangle. From the lower dorsal region, pus may infiltrate poste- 
riorly and appear as a lumbar abscess on the back. 

Abscesses starting from lumbar caries may also present in the 
same places, in the loin, the iliac fossa, or in Scarpa's triangle; they 
have, in rare instances, perforated the sigmoid flexure of the intestine. 

Abscesses starting from the sacro-iliac junction and the sacrum 
may point either in the ischio-rectal fossa or superficially over the 
sacral region and buttocks. 

Abscesses occur in about one-fourth of all cases. The cause of 
abscess has already been alluded to under Pathological Anatomy, 



214 



ORTHOPEDIC SURGERY. 



Paralysis. — The paralysis is a motor one, usually without sensory 
disturbances, and rarely are the bladder and rectum affected. In 
cervical caries, the arms and muscles of the trunk are seldom in- 
volved. The paralysis always paraplegic, is usually incomplete, a 
paresis. Children walk around, but want to lie down a good part 
of the day, they easily trip and fall, find difficulty in going up stairs, 
and sometimes totter. Their knee-jerks are greatly increased and 
ankle clonus is present even when the paralysis is slight. Duration 




Fig. 109. — Method of taking an outline of spine with Young's tracer. 



of paralysis is variable, — it usually lasts two or three months, and 
may be recovered from after two years. About one-fourth of the 
children attacked by the disease have paralysis. A child is likely 
to have several attacks if he has it once. 

Diagnosis. — Diagnosis of Pott's disease offers no difficulties 
if deformity be present. Early recognition may present some 
difficulty and the history of the symptoms is never suggestive. 
The diagnosis is made chiefly on the physical examination. 
Before deformity comes, there is muscular spasm of the spinal mus- 
cles which gives rise to a peculiar attitude and gait, and an intelli- 
gent study of these postures shows that it is the stiffness of some 
part of the spine which produces them. Muscular spasm is detected 
by certain tests. These are, to ask the patient to pick up an object 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 215 

from the floor, to have him sit on the table with the knees extended 
straight ahead and grasp his toes, lie on the face while the surgeon 
lifts the legs and bends the trunk, first backward and then from side 
to side; to this is added the examination of the neck for stiffness in 
the muscles by nodding and extending the head and side turning. 
Two other factors may embarrass the early diagnosis of Pott's disease 
— they are lateral deviation of the spine, and paralysis before the com- 
ing on of deformity. 

Lateral deviation may be mistaken for lateral curvature. It may 
precede the appearance of deformity, but in Pott's disease it is 
always associated with spasm and rigidity of spinal muscles and a 
leaning of the trunk to one side without any curving of the 
spine, and rotation of the trunk is very seldom observed. The slightly 
raised temperature which characterizes tuberculosis of bone is also 
an aid in the diagnosis of doubtful cases. 

Paralysis appearing before 
the deformity has often been 
misleading. It is to be sus- 
pected when increased knee- FlG - "o.— Tracing of spine of another 
1 child, 

jerk and ankle clonus are 

found in association with rigidity of the muscles of the back and 
neck. The temperature chart and the X-ray picture are good guides 
to follow. 

Deformity. — The presence of deformity while it makes diagnosis 
plain, entails the necessity for a reliable record of the degree and 
amount of deformity, for it is obviously necessary to know at 
some future visit whether the deformity has increased or receded. 
This is easily done by making a tracing of the outline of the 
spine as the child lies prone on the table, cutting from it a pat- 
tern in stiff paper or leather-board and trying on and if necessary 
recutting and fitting it. This pattern can be kept and tried on at 
any time, first placing the child in the original position. To make 
a tracing a strip of lead may be pressed down on the spine, care- 
fully lifted and laid on edge on a sheet of paper, and traced; it 
should be a half or three-quarters of an inch wide and eighteen 
inches long, and about an eighth of an inch thick so as to be firm 



2l6 ORTHOPEDIC SURGERY. 

to keep its shape. An ingenious devise is the one shown in the 
illustration made by Dr. E. B. Young, of Boston; it consists of a 
wooden bar with a slot in which a number of pieces of wood of equal 
length play, which are clamped in place by a screw at one end. 

Diagnostic Difficulties. — Cervical caries may be mistaken for tor- 
ticollis, sprain, stiff wry-neck from inflamed glands, etc. Some- 
times a correct diagnosis can only be made by watching the tempera- 
ture, the location of rigidity, by increased knee-jerks and ankle clonus, 
by pains referred to the terminals of the nerves, and by a careful 
examination by palpation to detect the presence of a possible abscess. 
Again, the X-ray and temperature chart are of assistance. Round 
shoulders with stiffness is sometimes hard to differentiate but the 
absence of real muscular spasm and watching the temperature are 
usually good guides for diagnosis. 

In the lumbo-dorsal region of the spine, a rounded kyphosis 
which is seen in the florid stage of rickets, the rhachitic spine, 
may be misleading in little children, but here, too, muscular spasm 
and a rise of temperature should be absent from rickets. Appen- 
dicitis and other intra-abdominal inflammatory conditions have been 
found in rare instances to simulate lumbar caries or vice versa. 
While abdominal conditions characterized by great pain, tenderness, 
and spasm of the abdominal muscles may produce a spinal rigidity 
from spreading of the muscular spasm, it is very rare for the spasm 
of the dorsal muscles in Pott's disease to extend to the abdominal 
muscles. In a few cases, twelve to twenty-four hours of watching 
has been necessary before the true nature of the condition could be 
made out. But psoas abscess with acute inflammation of iliac 
lymph glands may simulate appendicitis closely. 

Arthritis of the spine is rarely mistaken for true caries because 
pain, sleeplessness and nervousness, are much in evidence as they 
also are in the typhoid spine but here the presence of the Widal 
reaction is conclusive. 

Cancer of the spine may simulate Pott's disease in old people, 
but the pain is very severe and generally it is in the back; collapse 
and weakness come on early and the downward progress is rapid. 

Spondylitis deformans is characterized by a stiff straight back in 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 217 

adults and here, too, the pain is chiefly in the back. The diagnosis 
may be demonstrated by the X-ray. 

Repeated examinations may be necessary to differentiate between 
the neurasthenic or railroad spine and Pott's disease. Atypical 
symptoms, the absence of reliable physical signs, and a persistently 
normal temperature, — these three are sufficient to exclude tubercu- 
losis of the vertebrae. 

Prognosis. — Cases of cervical and lumbar caries recover sooner 
and with less deformity than do the dorsal ones, and are often well 
in three years. The tendency to deformity is less because the dis- 
eased portion of the spine starts in a physiological lordosis. Good 
care, early treatment, absence of fever at the time of onset — these 
are favorable signs: Progressive and rapid growth of abscesses and 
the rapid development of great deformity are unfavorable. Pul- 
monary tuberculosis, acute miliary tuberculosis, prolonged suppur- 
ation with amyloid degeneration of the spleen, liver, and kidneys 
and exhaustion — these are the causes of death. With good care 
the mortality is small. Tuberculous meningitis claims much fewer 
victims in Pott's disease than it does in hip disease. Those with 
large abscesses have a poor prognosis. As to paralysis, about 
85 percent of paralytic cases recover entirely. The prognosis as to 
the extent of ultimate deformity depends largely upon the amount 
present at the beginning of treatment and the kind of care 
given the child. One cannot ordinarily hope to improve or do 
away with deformity but one should always prevent its becoming 
worse, and in many cases, improve the general bearing and attitude. 

TREATMENT. 

Treatment is divided into general and local treatment. 

General Treatment. — Hygiene and care takes the place of drugs, 
and the general treatment is the same as for tuberculosis of 
the lungs. The patient should have an abundance of nourishing 
food, fresh air day and night, out of doors if possible, even in winter, 
and the activities be restricted by the indications of the temperature 
chart. All these should be attended to, and then the child may be 
out, wearing a brace or jacket which fixes the spine sufficiently. 



2l8 ORTHOPEDIC SURGERY. 

This treatment should be persisted in for several years until con- 
valescence is accomplished. As braces are at best mechanically 
imperfect, recumbency is employed at times to reduce traum- 
atism of the spine to a minimum. For how long this should be 
done, is a matter of opinion, for many are in favor of keeping 
all cases of dorsal caries, which remain in good health, on their backs 
until the stage of convalescence is about over, in order that they 
may be spared deformity; others consider recumbency for months and 
years as unphysiolcgical for a child, preferring as a half-way course 
ambulatory treatment, tempered with daily periods for lying down. 




Fig. hi. — Go-cart made on the wheels of a child's tricycle. 
(Childroi's Hospital.) 



The go-cart is a great help, as it does away with the irksomeness 
of lying in bed and enables the patient to move himself about out 
of doors. At the Sea Breeze Home, Manhattan Beach, a small 
donkey is occasionally attached to the go-carts and the little 
patients on frames drive him about the beach. Sleeping out of doors 
in a tent or shed can be done in New England the year round, if 
arranged to protect from the wind and weather, and enough warm 
clothing and bedding be used in winter and some sort of heat- 
ing apparatus be employed in the shack in which the patient sleeps. 
This has been done for five winters at the Convalescent Home of 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 210. 



the Children's Hospital, at Wellesley. The sheds in which the 
children sleep are often below 20 F., but there is steam heat, and 
either side can be kept open. The improved color, appetite, and 
strength of children living out in these shacks, are in marked con- 
trast to the condition of those in the hospital ward. They all gain 
markedly, both in weight and in the percentage of hemoglobin, unless 
an abscess is coming. 

The use of drugs is as unsatisfactory as in pulmonary tubercu- 
losis. Koch's tuberculin promised much but accomplished little 
for tuberculous bone disease. It is now receiving a 
new trial by those who are studying the effect of 
Koch's new serum upon the opsonic index for tubercle 
bacilli. Two little children have received this treat- 
ment under the writer's care recently at the House of 
the Good Samaritan, their general health is greatly im- 
proved, their opsonic index for tubercle bacilli has been 
raised, and they are apparently doing well. 

It is probable that open air, rest, and increased 
nutriment may affect the phagocytic power shown by 
the opsonic index in the same way that the small 
subcutaneous doses of tuberculin do. 

Local Treatment. — Local treatment aims to improve 
the form of the spinal column, to fix it, as it were, in p IG> II2 .— 
splints and hold it there. Recumbency in addition Low dorsal 
removes the harmful effect of the body-weight, but i umD ar ab- 
proper recumbency for Pott's disease is secured only sccss. 
by means of apparatus, — lying in bed does not do it. 

Recumbency. — The indications for recumbency are, (1) wmenever 
the symptoms are very acute; (2) when the child's condition under 
ambulatory treatment is unsatisfactory; (3) when paralysis is com- 
ing or is already present; (4) when lateral deviation or psoas con- 
traction makes the support inefficient. 

Of the various appliances for securing recumbency in bed 
in Pott's disease, we will mention the bed frame of Bradford, 
the stretcher frame of Whitman, and the plaster bed of Lorenz and 
Hoffa. 




220 



ORTHOPEDIC SURGERY. 



The bed frame of Bradford maintains a horizontal recumbent posi- 
tion. It is a rigid rectangular frame, usually made of four pieces 
of f-inch galvanized iron gas pipe screwed into an elbow at each 
corner; one of the elbows has a reversed screw thread to allow of 
putting the whole together. The frame should be as wide as the 
distance between the tips of the shoulders, its length exceeds the 
height of the patient by a few inches. It is covered with cotton sheet- 
ing, double thickness, put on in two pieces with a four inch space 
between them. The covers should be cut three times the width 
of the frame; doubling makes them J width so that they may be 
tightly laced on the back of the frame, with a sail needle and stout 
cord. The four inch space between the upper and lower covers permits 
the use of the bed-pan without disturbing the position of the child. 
Two folded linen pads are laid lengthwise on the frame with a space 




Fig. 113. — Bed frame of Bradford. 

between to prevent pressure on the spinous processes; they raise 
and hyperextend the spine. In putting the child on the frame, 
he should lie on his side, the frame already padded is placed against 
his back while the nurse's hand, pressing upon his chest, holds him 
firmly against the padding and the frame is slowly tipped down 
flat upon the bed; he wears an undershirt, a cotton or cotton- 
flannel night-gown, opening behind. To prevent his twisting and 
turning, two webbing straps are buckled around the child and the 
frame like a soldier's cross-belts, a towel is pinned around the pel- 
vis and frame, and in lumbar disease, a second towel around the 
knees; an empty pillow case or a very flat hair pillow is allowed. 
Lying face down, the back is bathed morning and night with alcohol 
and powdered with talc. Liquids are given through a tube or 
"feeding duck," and a child soon learns how to eat. While on the 
frame, he is easily wrapped in shawls and blankets, sent out doors 
in a go-cart, or carried out for a drive. The only real difficulty 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 221 

in having such children sleep out in cold weather, comes from 
the little ones who need frequent changing in the night. 

The stretcher frame of Whitman is much narrower and it is bent 
to make the back hollow. It is similarly made of gas pipe, four or 
five inches longer than the child but only four-fifths of the width of 
the ordinary bed frame,— that is, the sides of the frame are under the 
glenoid cavities and the acetabula. The cover is a single piece of 
stout canvas tightly laced on the back of the frame from end to end. 
It is well to apply a bandage tightly about the frame where the trunk 
will rest, to give firmer support, before the cover is put on. Three 
or four buckles are sewed on the under side of the cover near the side 




Fig. 114. — Stretcher frame of Whitman. 

bars to attach an apron like the apron of a back brace. Felt pads, 
I of an inch thick, are sewed to the canvas so as to press on either 
side of the spinous processes and protect them from rubbing. The 
frame is bent to hyperextend the spine, — at first very little, — increas- 
ing the bend from day to day until both the deformity and the phys- 
iological dorsal curve are completely obliterated. When the back 
is sufficiently arched, the head and legs, by their weight, exert a 
little traction. 

In order to bathe the back or change the clothes, the child on its 
frame is laid, face downward, on a large pillow, the under side of 
which is built up so as to maintain the extended position while the 
frame is removed. Some prefer to have two frames using each on 
alternate days. The outer garments include both frame and child. 

The Plaster Bed. — The method of making the plaster bed is de- 
scribed in Chapter XX, page 336. The patient is secured by bandag- 
ing the trunk to the plaster bed, sometimes the forehead as well. In 



222 ORTHOPEDIC SURGERY. 

high dorsal and cervical disease, Lorenz uses the jury mast incor- 
porated into the plaster for traction. At the first daily bath, the 
back should be examined for areas reddened by pressure, and the 
padding should be correspondingly altered. Daily removal and 
reapplication of the plaster shell is done in the same way as with 
the Whitman frame. Since a child in a plaster bed is easy to carry 
about, he should have abundance of fresh air out of doors, plenty 
of nourishing food must be given, and freedom to kick his legs 
about will add much to his comfort and aj: petite. When the home 




Fig. 115. — The plaster bed with head traction for cervical caries. 
(Children's Hospital.) 

is such that the plaster bed cannot be used intelligently, the plaster 
jacket with or without head piece is a good substitute for the recum- 
bent treatment. (See Chapter XX, page 334.) 

The plaster bed is much used in Europe. Hoffa believes that 
the only efficient fixation of the diseased column is obtained when 
the patient lies on his back with the whole spine in hyperextension 
and stays so until the diseased spine consolidates. He prefers the 
plaster bed because the patient can be easily carried about out of 
doors, and can, therefore, receive better general treatment. He 
continues the recumbency until every vestige of tenderness and 
spasm is absent from the back and the child can stand and walk 
with unrestrained attitude and movements. He considers it better 
to keep the patient lying down too long than too short a time. 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 223 



Ambulatory Treatment. — This form of treatment certainly dates 
back several centuries. Ambroise 
Pare has a chapter on "amending 
the deformity of such as are 
crooked backed. " He had them 
wear "breast-plates of iron full of 
holes all over them, whereby they 
may be lighter, and they must be 
so lined with bombast that they 
hurt no place of the body. These 
plates will do them small good who 
have attained their full growth." 
He does not claim this as his own 
invention for many mechanicians 
had world-wide reputations for 
cures they effected. 

The steel brace is an efficient 
means of treatment for lumbar and 
cervical cases throughout the dis- 
ease, unless some special indica- 
tion arises which demands recum- 
bency. Its efficiency is less in the 
dorsal region because here the 
spine is already curved in the 
direction the disease bends it. For 
a description of the brace and its 
various modifications, see Chapter 
XXI, page 350. 

For cervical disease, cervico- 
dorsal disease and those cases of 
high dorsal disease in which am- 
bulatory treatment has to be re- 
sorted to, certain modifications 
have to be added to the brace 
and jacket to support the head. 
(See Chapter XXI, page 353.) 




Fig. 116. — Shows the pressure 
mark of an efficient brace applied 
for lumbar caries. 






224 ORTHOPEDIC SURGERY. 

These are the Thomas collar (p. 357), the Taylor ring head support 
(p. 353), the wire chin rest, (p. 354), and Goldthwait's head support 
(P- 355)- Instead of steel braces, the plaster-of-Paris jacket of Sayre 
has been used by many surgeons since 1874 and it is still preferred by 
many to any other form of ambulatory treatment. It was employed 
with forcible correction by Calot and Chipault, in France, twelve 
\ears ago, but this procedure has been abandoned. The several 
methods of applying plaster jackets in the recumbent position, will 
be found in Chapter XX, pages 333-340. 

Beely, Schede, Wullstein, Hoffa, R. T. Taylor, and others, use 
strong traction combined with pressure from levers and screw pads 
to correct the deformity during the application of jackets. In real- 
ity, they are using in a modified and milder form, Calot's forcible 
correction, only without anaesthesia. 

TREATMENT OF COMPLICATIONS. 

Paralysis. — Adolescents and adults are often cured of attacks of 
paraplegia by the application of a plaster jacket in the corrected 
position of the spine. In the child, this improvement is less fre- 
quent. This may be due to greater difficulty in maintaining over- 
correction during the application and setting of a jacket because 
the back is so short. For the child, overcorrection on the Whitman 
frame, combined with traction on the head and legs is more efficient. 
One must remember that paraplegias recur. Traction on the head 
and feet may also be made on the bed frame of Bradford or the plas- 
ter bed. It has occasionally been observed that the draining of 
abscesses causes immediate disappearance of paralysis. During 
the paralysis, electricity, massage, and passive gymnastics should 
be used daily. 

Laminectomy. — The operation of laminectomy for the relief of 
paralysis in Pott's disease, has been attempted at times since 1882; 
costo-transversectomy of Menard has also been used; neither are 
free from danger; a mortality of 50 percent has occurred in laminec- 
tomy operations and on account of the large mortality and the com- 
paratively few good results obtained, many advise against these 
operations for paralysis. It is also difficult to know when they should 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 225 

be done, for we are told by some that the operation is not to be under- 
taken too soon after the onset of paralysis, because the paralysis 
might get well of itself; others tell us that it is not to be done too late 
for it is useless if the pressure paralysis of the cord has produced an 
incurable lesion. 

The operation of laminectomy is, therefore, chiefly done for the 
relief of pressure from the fragments of a fracture of the spine, or to 
give access to the cord for the removal of a tumor. In deciding upon 
the operation, one should remember the high mortality, that many 
of those who survive are not improved, for one cannot estimate 
beforehand whether the amount of damage already done to the cord 
substance will or will not admit of repair. 

Murphy, of Chicago, opens the spinal canal by a simple longit- 
udinal incision down the sides of the spinous processes; on either 
side a blunt dissection of the laminae is carried as far as the trans- 
verse processes; then he punctures the lamina: with a special conical 
drill and cuts them with a rongeur, and a bone cutting forceps of 
special design, on both the right and left sides of the column. He 
removes the laminae and spinous precesses of three or four verte- 
brae, gently displacing the cord to one side; and if he exposes granu- 
lomatous tissue on the posterior surface of a vertebral body, he curettes 
it and fills the cavity w r ith a plug of Moorhof 's filling for bones. The 
wound is closed without drainage. From six months to two years 
may be required to get well of paralysis where sequestra have been 
removed from the spinal canal or an abscess in the spinal canal has 
been drained. Scars have sometimes re-opened after healing and 
subsequently closed again. 

Abscess. — Treatment for cold abscesses in Pott's disease is still 
sub jit dice. In the pre-antiseptic days, the let-alone policy prevailed; 
with the coming of aseptic surgery, came also free drainage and 
curettage of diseased vertebra and of abscess cavities; then less rad- 
ical means were advocated. Aspiration combined with the injection 
of iodoform emulsion is in favor in many parts of Europe and in 
some places in this country. Most surgeons follow a middle course; 
they immediately drain all abscesses which threaten life, — like the 
retro-pharyngeal or mediastinal, those with high fever and great 
15 



2 26 ORTHOPEDIC SURGERY. 

prostration, those which persist many months without diminishing, 
and those ready to break externally. A retro-pharyngeal abscess 
may be opened in the throat and sometimes in the side of the neck. 
In opening one of these in a baby's throat, it is well to have him held in 
the lap of an assistant in front of the surgeon; the mouth is held wide 
open with a gag, while the surgeon with one finger feels the bulging fluc- 
tuating posterior pharyngeal wall and quickly guides the tip of a guarded 
knife to open the cavity. The patient must be immediately inverted 
to prevent his sucking pus into the larynx. A mediastinal ab- 
scess is reached by resecting the transverse process and the rib at- 
tached to it, then by doing a deep dissection along the pedicle and the 
side of the body of the vertebra subperiosteally with a long blunt 
pointed periosteal elevator, all the important structures are avoided. 

A boy is now at the Convalescent Home who underwent this 
operation. He has a very small knuckle at the fifth dorsal spine and 
is in excellent health. The wound through which his mediastinal 
abscess discharged has been closed for two years. Abscesses of the 
posterior mediastinal space, like the retro-pharyngeal, endanger 
life and demand instant relief. The other spinal abscesses are less 
urgent. 

The timidity of surgeons today is often in marked contrast to the 
boldness which characterized the draining of extensive cold abscesses 
in Pott's disease several years ago. 

SACRO-ILIAC DISEASE. 

This affection is never very common but in children it is rare. 
It is also called sacro-coxitis, sacrarthrocace and sacro-coxalgie. 
It is rather more common in men than in women. It is generally 
a tuberculous infection of the bone but other organisms may cause 
typical symptoms of the disease. Traumatism and strain frequently 
cause it; it has been attributed to the strain of parturition. In chil- 
dren the bone infection is more acute than in adults; there is greater 
tendency to necrosis. 

In 1890, Van Horn knew of only 6 children under ten years of 
age, out of 72 cases of sacro-iliac disease. 

The differential diagnosis between sacro-iliac disease and tuber- 



CHRONIC INFLAMMATION OF THE BONES AND . JOINTS. 227 

culous disease of the last lumbar vertebra and of the sacrum 
is extremely difficult because the process almost always begins as 
an acute bone inflammation on one side or the other of the sacro- 
iliac joint. In children, the pain is apt to be very acute, and is referred 
to the middle of the back, the side of the pelvis, the buttock, or the 




Fig. 



117. — Sacro-iliac disease with a sequestrum in the ilium. 
{Children's Hospital, A. W. George, Radiographer.) 



thigh. Certain movements, like sudden coughing and laughing, 
bring sudden twinges of pain. In standing the body usually inclines 
toward the sound limb. Lying down relieves the pain and removes 
the peculiar feeling of insecurity and weakness. Tenderness over 
the joint is usually elicited by pressure and the finger often detects 



2 28 ORTHOPEDIC SURGERY. 

swelling and thickening. If the disease has lasted long enough, 
sudden, lateral compression of the iliac crests a manipulation 
which slightly moves the joint, is painful. Abscess formation is the 
rule. The pus routes may be a simple superficial pointing over the 
crest of the ilium near the posterior superior spine, or it may burrow 
through the sciatic notch and appear in the ischio-rectal fossa, or 
break into the rectum, or cause an accumulation under the fascia 
covering the iliacus muscle and point in the groin, like an abscess of 
the ilio-psoas in Pott's disease. 

Four conditions may be mistaken for it, lumbago, sciatica, hip 
disease, or Pott's disease. A positive diagnosis is sometimes only 
reached after watching the case for some time; but tenderness over 
the sacro-iliac joint and pain on compressing the wings of the innom- 
inate bones are very significant. The affection is extremely chronic ; 
many of the children have with it extensive necrosis, prolonged 
suppuration, and die of exhaustion. 

Treatment. — In view of this, treatment guided by the radio- 
graph, should be directed to early removal of the focus of inflamma- 
tion in the bone, or at least, opening up the cortical bone and drilling 
through into its interior as is done for early osteomyelitis. Ab- 
scesses should be drained early by small incisions; excision of the 
sacro-iliac synchondrosis may be reserved for severe cases. 

General treatment should be directed to upbuilding the general 
health by a generous nutritious diet and by living out of doors. The 
new treatment, the subcutaneous injection of an emulsion of a ster- 
ilized culture prepared according to the method of Wright from a 
culture of the organisms found to exist in abscess, offers a new method 
of attack and should be given a trial for chronic sinuses. 

In the case of a boy of 4 who had had an ischiorectal abscess dis- 
charging for two years, the writer found an abscess in gross appear- 
ance like a large hydronephrosis or a cystic kidney. Upon incising 
the abscess, three sequestra were discovered on the iliac side of the 
synchondrosis and considerable softened, carious bone was curetted 
away from both ilium and sacrum. The abscess wall showed many 
giant cells in a tissue resembling granulation tissue; several giant 
cells contained tubercle bacilli and cover glass smears of pus showed 



CHRONIC INFLAMMATION OF THE BONES AND JOINTS. 229 

tubercle bacilli. The boy improved considerably but a sinus per- 
sisted and he died about a year after the operation, of pneumonia. 
All children are not as badly off. Prof. L. A. Sayre, of New York, 
reported the case of a child, 2\ years old, who fell behind a trunk, 
and later developed a lumbar abscess which was drained three times 
but always refilled. Dr. Sayre removed a sequestrum from the 
joint and the patient grew to be a strong man, dying of an accident 
at the age of 32. 



CHAPTER XV. 

TUBERCULOSIS OF BONES AND JOINTS (CONCLUDED). 

HIP DISEASE. 

Hip disease, is known as hip- joint disease; morbus coxarius; 
morbus coxae, chronic articular ostitis of the hip; coxitis; German, 
Huftgelenksentziindung; French coxa tuberculose; coxalgie; cox- 
arthrocace; Italian, malocoxario; coxite; coxotuberculosi; Spanish, 
coxotuberculosis. 

Hip disease, though a distinct and well-defined process in the 
human body with well-studied symptoms and signs, is neverthe- 
less a disease in which errors of diagnosis are often made, for it 
is easy to overlook it and it is also easy to misinterpret other con- 
ditions which resemble it in its early stages especially. While 
it affects both children and adults, the great majority of cases 
originate before the age of ten years. Almost the commonest of 
the bone-tuberculoses, it is more frequent in the right than in the 
left hip, and occurs twice as often in boys as in girls; it is de- 
cidedly uncommon in both hips (double hip disease), but it is 
often observed accompanying tuberculosis of other joints. In New 
England it is a little less common than Pott's disease but of more 
frequent occurrence than all the other forms of joint tuberculosis, 
for at the Children's Hospital in Boston in the forty-seven years 
of its existence there have been under observation and treatment 
2,502 patients with hip disease, 359 with Pott's disease, 427 with 
tuberculosis of knee, 416 of the ankle; and there were fewer in 
the other joints. 

Pathological Anatomy. — The pathology of hip disease differs 
but little from that of tuberculous ostitis in other joints, and in 
most cases the primary focus of disease is found in the head of 
the femur, near the epiphyseal cartilage or the articular cartilage. 
When the focus of disease reaches the surface, tuberculous pusper- 

230 



TUBERCULOSIS OF BONES AND JOINTS. 



231 



f orates the joint, the cartilage becomes thinned, in spots yellow, 
and ulcerated and the surface of the bone worm-eaten. This filling 
of the joint with tuberculous pus may produce a pathological dislo- 
cation, but this is very rare, although a partial destruction of the 
femoral head, migration of the acetabulum and a distorted position 
of the limb may simulate a dislocation. 




Fig. 118. — Right hip disease with abscess in a child with coxa valga. 
Note the indistinct outline of affected joinl, small bone and thin cortex 
of femur. The right side of pelvis is small. (Cnildren's Hospital, A. W. 
George, Radiographer.) 



The shaft of the femur undergoes rapid atrophy beginning with 
the onset of disease and it is demonstrable by X-ray. Owing to 
the destructive ostitis, and atrophy, the neck of the femur may 
spontaneously fracture or the epiphysis separate and surgeons 
have often had to remove the loose head of the bone. Some- 
times the whole articular cartilage is lifted from the bone by granu- 
lations; sometimes the head of the femur disappears altogether. 



232 



ORTHOPEDIC SURGERY. 



The acetabulum may be perforated by destructive ostitis. Inside 
of the pelvis a dense wall of fibrous tissue forms with pus between 
it and the bone, the swelling may be felt through the rectum. 
More often the disease causes a weakening of the upper part of the 
acetabulum for the muscles and the body-weight drive the femur 
upward producing destruction and eventually an enlargement here 
and a migration of the acetabulum upward. This migration is 
one cause of short leg which is usuallv overlooked. 




Fig. 119. — Healed hip disease with ankylosis in abduction in an adult. 
(A. W. George, Radiographer.) 



Disease may spread in the pelvis beyond the limits of the acet- 
abulum. Abscesses in time frequently become superficial, for 
the pus from the bone or joint burrows or the disease spreads to 
the peri-articular tissues, or separate foci of disease may develop 
in the bursas or soft parts around the joint. Pus may get inside 
the pelvis from disease of the femur, spreading through the bursa 



TUBERCULOSIS OF BONES AND JOINTS. 



233 



between the hip and the psoas muscle into the iliac fossa and 
gravitating to a point on the interior opposite the acetabulum. 
In time nature may absorb or calcify this tuberculous debris or it 
may be discharged into the rectum or bladder, or externally. 

Malpositions, shortening of the leg, and impairment of the general 
health, characterize advanced cases. After recovery, which is often 
with ankylosis and malposition, the autopsy of a healed case 
reveals cheesy foci which are still ac- 
tive, though encapsulated. These are 
the cause of late relapses of the disease 
and of the fresh inflammation after 
forcible manipulations to correct de- 
formity. 

Clinical History. — The onset is gen- 
erally insidious. Lameness there is 
with remissions and often night-cries, 
crying out in the sleep, but the onset 
may come abruptly and suggest trauma. 

Stiffness. — A stiff gait in the morning 
and after sitting for awhile is an early 
symptom. The limp is generally less 
at night than in the morning and the 
walking child avoids having weight 
long on the affected limb. The knee of 
the affected side, in standing, is often 
slightly bent, the pelvis tips down, and 
the thigh is slightly abducted, as may be 
seen by the deviation of the fold between 
the buttocks from the median line. 

Lameness, but little noticed at first, is usually well marked within 
a month of the onset. Walking is not painful except in a few severe 
cases. Malpostures of the hip give rise to a variety of peculiar 
attitudes and gaits. 

Pain, if present, is usually referred to the knee, and the front of 
the thigh. As it progresses, stiffness increases, malpostures add to 
the increasing lameness and disability, and there may be exquisite 




Fig. 120. — Right hip disease 
with shortening. (Children's 
Hospital.) 



234 ORTHOPEDIC SURGERY. 

pain and tenderness in the thigh and knee. Still later, abscesses 
form and the general health is impaired. Pain and sensitiveness 
may be absent throughout the course of the disease. Few cases 
have any pain in the hip- joint. In the acute period, pressure over 
the trochanter or over the anterior surface of the joint may cause 
complaint. 

S el j- protection. — The child in bed is often observed to place the foot 
of the well limb under the lower part of the other leg and so uncon- 
sciously protects the hip from moving, or with the toes of the well 
foot pressing on the dorsum of the other, exerts traction. 

Sensitive Joint. — There is often great variation in the amount of 
joint sensitiveness present, and the hip movements are restricted 
by muscular spasm to a varying degree, which however has nothing 
to do with joint tenderness. At times very sensitive joints may 
be flexed, extended, abducted and adducted with comparative 
freedom, provided that it be done very slowly and the child's con- 
fidence secured. Only rapid movements cause pain, crying, and 
fixation; on the other hand, a child whose hips are rigidly fixed by 
spasm will often have no pain. The clinical significance of this is 
not known. 

Spasm Restricting Motion. — When the limit of motion in a given 
direction is reached, muscular spasm stops it. Normal movements 
may be slightly or much restricted by it. 

Night cries are present sooner or later in children with hip 
disease. As the child drops to sleep, the muscles which fixed the 
hip in a painless position gradually relax and as the hip- joint moves 
in consequence, the child awakes with a startled cry and does not 
know what hurt him. Night-cries are typical of most forms of 
chronic tuberculous joint disease, and are most frequent in 
disease of the hip and knee. 

Atrophy. — When the child is stripped for examination, the sur- 
geon immediately notes wasting of the muscles of the affected limb, 
often with slight shortening, for muscular atrophy, bone atrophy, 
and true shortening are usually present early. Their cause in 
unknown; though many theories have been advanced about it, 
recent experiments on rabbits, by A. T. Legg, point to its coming 



TUBERCULOSIS OF BONES AND JOINTS. 



235 



from disuse. Bone atrophy is easily recognized in radiographs and 
is present not only in the whole of the femur but also in the other 
bones of the leg. Bone atrophy is characterized by diminished 
resistance to the passage of the X-rays so that, in developing the plate, 
the bone shadow begins to clear up and show details of structure 
while the shadows of tendons are still visible on the negative. The 



Fig. 121. — 
Cured hip 
disease with 
shortenin g. 
Method of 
determin i n g 
heightof high 
sole. 




Fig. 122. — 
Hip disease 
with shorten- 
in g, shows 
the atrophy 
of muscles of 
thigh and leg. 




Fig. 123. 
Double hip 
disease with 
flexion de- 
formity. 
(Children's 
Hospital.) 



cortical bone of the femur is noticeably thinner than its fellow and is 
sharply penciled. The examination of the patient should, there- 
fore, include a radiograph of the affected hip. 

Physical Examination. — While the child walks about stripped 
from waist down attitudes and gait are carefully studied, special 
attention is given to detect hip-flexion and restricted movements. 
These are then tested by certain measurements with the patient 
lying on a folded blanket on a table, and a record is made of 



236 



ORTHOPEDIC SURGERY. 



the amount of permanent malposition, of the joint motions, and 
of atrophy and shortening. To detect slight degrees of fixed 
hip-flexion the surgeon grasps the well leg below the knee, 
flexing the knee upon the body to the limit of motion. This manoeu- 
vre, devised by Thomas, brings the sacrum flat on the table and, 
if there be permanent flexion of the hip, the knee on the affected side 
rises to show the amount of permanent hip-flexion. To test permanent 
adduction or abduction one makes a line connecting the anterior 

superior spines perpendicular to the 
axis of the trunk when the difference 
in direction between the axes of trunk 
and limb shows it. By these two 
manoeuvres, the permanent flexion of 
the hip, and the permanent abduction 
or adduction deformity of the sus- 
pected hip are recognized and the 
amount is easily estimated in degrees 
after a little practice. 

Shortening. — The length of the leg 
from the anterior superior spines to 
the internal malleoli is then recorded 
(showing actual shortening), and the 




circumferences of the two thighs at the 



Fig. 124. — Hip disease healed 
with a half-inch shortening a * 
and almost perfect motion. 
Unusual result. {House 0} 
Good Samaritan.} 



)erineum are compared and the calves 



their largest diameters to show 



atrophy. 

Hip Motion. — There remains the 

estimation of the amount of joint 
motion. Grasping with one hand the pelvis by placing the fingers 
on the ilium and sacrum and the thumb on the anterior supe- 
rior spine, the surgeon with his other hand gently, slowly flexes the 
knee until a position is reached where the commencing, pelvic tip- 
ping shows that further motion is prevented by spasm. This point 
is the limit of motion in flexion and the number of degrees trav- 
ersed by the thigh represents the amount of flexion allowed by the 
hip. Abduction and adduction are estimated by a similar test 



TUBERCULOSIS OF BONES AND JOINTS. 237 

of lateral movements. The legs are then straightened and the 
surgeon gently rolls the thigh as far inward and outward as spasm 
allows, making a record of the amount of inward and outward rota- 
tion permitted in the joint. Then with the child on his face, hyper- 
extension of the hip is easily estimated by grasping the ankle, flexing 
the knee and lifting. The normal amount of hyperextension is 
about 30 . 

The physical examination is completed by feeling the two tro- 
chanters to detect enlargement, and by deep palpation to explore 
the iliac fossa and all the soft parts about the hip; brawny thickening 
and the presence of enlarged lymph nodes are often noted, the former 
arouses suspicion of abscess. The physical examination should in- 
clude a radiograph, and a record of the temperature and pulse and 
the general nutrition of the patient should be noted. 

The diagnosis of hip disease is based upon a history of gradual 
onset of lameness with remissions, usually following trauma, the 
kind of lameness, night-cries, restricted motion, the muscle 
and bone atrophy, shortening of the limb, or, in a few early cases, 
lengthening, and the slight elevation of temperature, which exists 
in all tuberculous bone disease of the joints. Rigid adherence 
to these diagnostic points will prevent the mistake of including many 
non-tuberculous conditions which simulate hip disease. 

Differential Diagnosis. — Among the conditions to be excluded are 
the following: strains of the muscles of the thigh, and enlarged glands 
of the groin from any cause, which may produce persistent flexion 
and pain on moving the thigh. Growing pains always arouse a sus- 
picion of hip disease, and usually repeated examinations should be 
made to eliminate it. Contusions of the joint or traumatic syno- 
vitis may simulate hip disease very closely and the diagnosis is 
often erroneously made, only to be corrected by the rapid and per- 
manent subsidence of symptoms. The joint infection usually called 
rheumatic fever, if confined to one hip of a child, simulates hip disease, 
but the fever is usually high, joint sensitiveness extreme, and cases 
often pass through a polyarthritis in which joints are successively 
invaded. Acute arthritis or epiphysitis of the hip-joint of infants 
is a far more acute process, with high fever, great constitutional dis- 



238 ORTHOPEDIC SURGERY. 

turbance, local heat, and swelling, indicating rapid abscess formation. 
Hip disease should never begin so acutely. 

Infectious arthritis after scarlet fever, diphtheria, pneumonia, 
typhoid fever, and other diseases is more apt to simulate the so- 
called rheumatic fever. If the infection be really a true osteomye- 
litis it should be recognized by radiographs. Gonorrhceal arthritis 
closely resembles hip disease in the adult, but the onset is usually 
very sudden and acute. Extra-articular hip disease, that is tuber- 
culous disease in the shaft, neck, or trochanter, may cause 
limping and pain with very little limitation from muscular spasm, 
and slight continual elevation of temperature. A radiograph offers 
for these cases the most accurate means of diagnosis. 

Arthritis deformans may pass for tuberculous disease in the 
adult. A careful physical examination of the rest of the body, will 
in most cases, give evidence of a general arthritic affection. In 
childhood, the temperature is usually not raised, although a slight 
elevation of temperature and an increase of pulse may be observed 
in the beginning. The type in children is called Still's disease, is 
polyarticular and usually painless. 

Hip disease may also .be confounded with certain conditions not 
in the hip-joint. For instance, the early stages of lumbar caries 
of the spine may simulate hip disease before the appearance of 
deformity because referred pains from lumbar disease may be 
confined to one leg or even to the sensory part of the anterior 
crural nerve, and unilateral psoas contraction flexes the hip and may 
produce a limp very like hip disease. In exceptional cases, disease 
in the sacral or lumbo-sacral region in young children gives 
rise to spasm of the muscles about one hip, but repeated careful 
examinations will usually show the true seat of disease. A Disease of 
the sacro-iliac joint is rare in childhood and is more often mistaken 
for lumbar caries than for hip disease. Careful observation of the 
muscles involved in the spasm, of the restricted movements of the 
hip and of the spine, and the atrophy and shortening of the leg, aid 
in discriminating hip disease from sacro-iliac. 

Inflammation of the bursae around the hip gives rise to swelling, 
tenderness, limitation of motion in certain directions, but extensive 



TUBERCULOSIS OF BONES AND JOINTS. 



239 



muscular spasm like that of hip disease is usually absent. It is 
sometimes, however, difficult to diagnose a hip disease which accom- 
panies bursitis. 

Knee-joint disease, tumor albus, is misleading only because the 
pain in hip disease is referred to the region of the knee, usually 
to the inner side. Careful physical examination should guide us 
to a correct diagnosis. 

Coxa vara produces shortening and limping. The trochanter is 
above Neltaon's line, but the hip motion is limited only in 
abduction. Radiographic confirmation of this diag- 
nosis should be made. 

Congenital dislocation of the hip-joint is so dis- 
similar that it is sufficient to mention the possibility 
of confusion from this source. Careful physical ex- 
amination and the radiograph should always lead to 
a correct estimation of that condition. Infantile 
paralysis during the acute stage of onset may exhibit 
marked pain, tenderness, and immobility of one or 
both legs, with fever and vomiting, but it lasts only 
for a couple of days and is superseded by loss of 
power, coldness, and rapid atrophy. Hysterical joint 
disease may resemble hip disease and require several 
painstaking examinations. As a rule, the prominent 
symptoms are atypical and variable, and are not con- 
sistent with one another. The radiograph and tem- 
perature chart are here of great value. Fracture of 
the neck of the femur in children is often a green- 
stick fracture, a traumatic coxa vara. Patients may 
walk a day or two after the accident with limping and discomfort. 
Muscular spasm is often present. The history of a fall of ten feet or 
more, the immediate disability, the shortening, the elevation of the 
trochanter, and the X-ray should establish the diagnosis. 

Prognosis. — The mortality of hip disease is greatly influenced by 
the care the patients receive. Cases in private practice do better 
than hospital cases; those under prolonged treatment in sanatoria 
better than those who come as out-patients from unhygienic homes. 




Fig. 125. 
Hip disease 
in adult 
healed in 
poor posi- 
tion of ad- 
duction. 



2/j.O ORTHOPEDIC SURGERY. 

In private practice the mortality is usually two or three percent. 
At Berck-sur-Mer, the great seaside sanatorium for Parisians with 
tuberculous bone disease it was twelve and one-half percent. The 
mortality of hip disease has been figured as high as twenty-five or 
thirty percent. The causes of death are phthisis, tuberculous men- 
ingitis, acute miliary or general tuberculosis, prolonged suppura- 
tion with amyloid degeneration, exhaustion, intercurrent diseases 
and septicemia. 

TREATMENT OF HIP DISEASE. 

Treatment. — The importance of general constitutional treat- 
ment in hip disease as well as in all tuberculous affections has been 
emphasized most strongly during the past few years. There has been 
a tremendous increase in the number of sanatoria dotted over the 
whole sea-coast of Europe. European physicians prefer the close 
proximity of the sea for non-pulmonary tuberculosis and high alti- 
tudes for pulmonary patients. In this country much less stress has 
been laid on seashore treatment, although a sanatorium for all the 
year round treatment has been established at Manhattan Beach and 
a number of seaside sanatoria are open during the summer months 
Open air, day and night, with proper restrictions, and allowance 
for weather; an abundance of nourishing food, and the restriction 
of exercise to a point which should never cause fatigue, should be 
insisted upon. 

Local treatment is, however, of great importance, and will be 
needed for, at least, two or three years, even if begun early, and 
joint protection for two or three years more, for the danger of relapse 
is great and often follows a too early discontinuance of treatment. 
Should acute symptoms not recur, flexion and stiffness may, and some 
shortening always, is expected. Distortions, however, should not be 
permanent and usually represent inefficient local care. Atrophy is 
never entirely cured but strong muscles are the rule. An abscess 
increases the danger to life but not the chance of subsequent de- 
formity. 

Two methods of orthopedic treatment have for many years ad- 
vanced rival claims in curing hip disease, the school of fixation, and 



TUBERCULOSIS OF BONES AND JOINTS. 



241 



the school of traction. An ideal treatment should combine both. Of 
recent years, Lorenz, of Vienna, has stoutly maintained that weight- 
bearing on the affected hip is to be encouraged, that hip disease is best 
cured by ankylosis with shortening in a position favorable for walk- 
ing, and he advocates the use of a short plaster spica bandage and free 
use of the leg in walking, except when acute symptoms come on, 
believing that in the end the shortening will be no greater although 
the trochanter may be elevated and the femoral neck depressed, 
because free functional use of the limb will increase bone growth 




Fig. 126. — Ordinary "and lateral traction for' hip disease applied to re- 
lieve persistent night-cries and sensitiveness. 



which is retarded by disuse in splints. During acute exacerbations 
recumbency is resorted to. It is an open question which of these 
methods have most abscesses. 

Recumbency. — During the acute period of hip disease, recumbency 
on the bed frame with traction prevents moving the joint and, if the 
weight be sufficient, stops muscular spasm. The pulley may be 
arranged as shown in the accompanying figure (Fig. 127) so that it 
pulls upon the diseased leg on the line in which it is held when the 
pelvis is square on the bed frame. If flexion is present, the pulley 
16 



242 



ORTHOPEDIC SURGERY. 



is elevated, if abduction or adduction, the leg is pulled more in or 
out. The amount of weight varies with every case; but it should be 
as much as can be borne without discomfort. The foot of the bed 
should be raised to furnish counter-traction. In using the bed-pan 
the frame should be raised and all movement of the hip avoided. 
Persistent night-cries and persistent sensitiveness of the hip call for 
lateral traction as well (see Fig. 126). Once a day the back should be 
washed with alcohol and powdered and the nurse should then use 




Fig. 127. — Traction in bed at the Children's Hospital; the leg elevated 
to accommodate slight permanent flexion of hip. 



great care that the hip-joint be not moved. Traction on the bed 
frame may be made on a go-cart, for the general treatment must not 
suffer during this period. 

Ambulatory Treatment. — When acute symptoms subside, ambu- 
latory treatment is in order. This should be given tentatively. The 
patient should get up for a short time mornings and afternoons, 
and should sleep wearing a splint instead of the weight and pulley. 



TUBERCULOSIS OF BONES AND JOINTS. 243 

Traction Splints. — The original traction splint was devised by 
Dr. Henry G. Davis, of Chelsea, Mass. Many modifications of 
this splint are in use today. For a description of splints for hip 
disease see Chapter XXI, page 364. Fig. 126 illustrates a method of 
applying adhesive plaster traction straps for use in bed or with these 
splints. Perineal straps are made of webbing covered with canton 
flannel or, in the case of small children where constant wetting can- 
not be avoided, the webbing may be passed through a piece of rubber 
tubing the size of the little finger. Properly applied extension in 
a splint demands constant care of the perineum to prevent chafing 
and excoriations. Alcohol and powdered talcum must be freely 
used. 

Fixation. — In acute cases or in acute exacerbations efficient fixa- 
tion is needed without traction. A plaster bandage from the toes 
to the axillae gives rest to the joint, and the long double spica, of 
course, prevents locomotion. It has been claimed that immobiliza- 
tion produces ankylosis. Fixation of a healthy joint even for pro- 
longed periods does not do so. Fixation for ambulatory treatment 
may also be obtained by the Thomas hip splint. (See chapter XXI, 
page 369.) 

Convalescent Splints. — Local treatment should be continued dur- 
ing the stage of convalescence, that is when muscular spasm can no 
longer be elicited. The hip is then sufficiently cicatrized to resist 
slight injury, but the frequent impact of the body-weight in walking 
might cause an acute exacerbation by lighting up a quiescent focus. 
The child may be told to swing the leg free from the ground, using 
crutches; or the traction splint may be provided at its lower end 
with a rubber crutch tip or a jointed socket to fit the boot. The 
length of the splint should be so regulated that the heel stays an 
inch off the ground to allow the child to walk upon the toes only. 
The high sole is no longer needed now but an ordinary boot is worn 
on the well foot. 

Length 0) Treatment. — Hip disease requires so long for its devel- 
opment that we must expect it to be a good while in going. It is 
safer to continue protective treatment and the convalescent splint 
until a long time has been given the joint in which to recover itself. 



244 



ORTHOPEDIC SURGERY 



Those apparently cured in childhood with a fixed joint or slight 
hip motion may suffer from painful acute attacks later in life. 

Osteotomy. — When, however, hip deformity persists permanently 
and causes lameness, correction is necessary. The choice of a 
method of correction will depend upon the state of the hip- joint. 
If true ankylosis be present, osteotomy below the trochanter mi- 
nor is demanded. If, however, a slight degree of motion be per- 
mitted in a hip- joint fixed by fibrous adhesions, manipulative correc- 
tion under anaesthesia or correction by recumbency and traction are 





Fig. 128.— Left hip 
disease with abduction. 



Fig. 129. — Ad- 
duction deformity 
in right hip disease. 



to be preferred. Should osteotomy successfully correct deformity 
in a hip which is not ankylosed, subsequent distortion may vitiate 
the result. Osteotomy performed below the lesser trochanter is 
known as Gant's operation. 

The patient, anaesthetized, lies on the side with a sand pillow be- 
tween the legs, and the skin of the field of operation is sterilized care- 
fully. The chisel is driven in an inch to an inch and three-quarters 
below the great trochanter, with the blade in the long axis of the limb. 
When it engages the bone it is turned so that the edge is at right angles 



TUBERCULOSIS OF BONES AND JOINTS. 245 

to the axis of the limb. The osteotome is then driven into the bone 
by sharp blows of the mallet, turning the cutting edge first forward 
and then backward, so as to cut obliquely through three-quarters of 
the entire cortex of the shaft. Lateral motions between each blow 
prevent the osteotome from becoming w T edged. It is better' not to 
divide the bone completely. Very little force is needed to complete 
the fracture of the bone, but if the femur does not readily yield, the 
chisel should again be driven in still farther, loosening it after each 
blow of the mallet, and directing the blade in a new direction. If 
necessary, bands of contracted fascia which prevent full extension 
and abduction may be divided. A small dressing of sterilized gauze 
is applied and the entire limb fixed in a carefully applied spica ban- 
dage extending to the axilla, padding the anterior spine, the iliac crest, 
patella, and spinous processes of the vertebras to prevent sloughing. 

The position in the spica bandage should be one of slight abduc- 
tion, the shorter the leg, the more abducted it should be. Hemor- 
rhage is rare. Six weeks in bed and six weeks up in a plaster bandage 
is the rule. Cases under sixteen years of age are apt to relapse after 
osteotomy, as they are more prone to fibrous than to true joint 
ankylosis. 

DOUBLE HIP DISEASE. 

Double hip disease is at best very disabling. During the acute 
stage recumbency and efficient traction followed by hip splints is 
the usual treatment here. During the painless stage a double Thomas 
hip splint makes it easy to carry the patient about. Fixation in 
plaster may also be employed, or locomotion may be permitted with 
double traction splints and crutches. Probably recumbency offers 
the best chance: Combined with the go-cart and open air treat- 
ment it may be used for long periods of time without injuring the 
general health. Hip disease in combination with caries of the spine 
is both disabling and exhausting. 

ABSCESS OF HIP DISEASE. 

At the present time abscess occurs in about 30 percent of all cases 
of hip disease. 



246 ORTHOPEDIC SURGERY. 

As already noted in the abscesses of Pott's disease, surgeons vary 
and fashions vary in treatment. The abscess of hip disease may be 
let alone, aspirated, drained by small or large incisions, the drainage 
may be combined with swabbing with chemicals, like pure carbolic 
acid, alcohol, iodine, etc., or with free curetting of the abscess walls. 
The tendency of many surgeons today is to open by small in- 
cisions without disturbing the interior, whether the abscesses are 
caused by liquefaction of old tuberculous detritus, 
or by tubercle and pyogenic organisms. J. S. 
Stone has used this method with good results in 
hip abscesses, but the choice of treatment must 
be made in each case separately. 

By other surgeons small circumscribed ab- 
scesses are incised freely, swabbed with carbolic 
acid, then with alcohol or with a 2^ percent solu- 
tion of formalin and the wound tightly closed by 
sutures, leaving a small drain to be removed in 
forty-eight hours. Such cases have healed by first 
intention and healed permanently, but the majority 
develop a fistula later. Free incision and curetting 
is now less employed than it was, because exten- 
sive channels are opened for absorption from ne- 
disease^bscess! 13 crot i c tissues left after curetting and for fear that 
the dressing, cannot be kept free from infection 
much longer than two weeks. 

The writer has little experience with aspiration of hip abscesses. 
In a few cases where he has employed it, the abscesses refilled 
later. 

Early Removal of Isolated Foci of Infection. — With the study of 
hip cases by means of the X-ray, this abortive treatment at once 
sprung into vogue. Starr, of Toronto, used it successfully on the 
knee. R. T. Taylor, of Baltimore, employed it enthusiastically 
for hip disease but later abandoned it. Other surgeons have had 
good results after the removal of foci in the vicinity of the great tro- 
chanter. Painter says that occasionally we become enthusiastic 
over our attempts to extirpate tuberculous foci in childhood. The 




TUBERCULOSIS OF BONES AND JOINTS. 247 

main objection to it is the unlikelihood of wholly extirpating the disease. 
He believes in the operation for adults undergoing a relapse, as he 
considers that there is much less likelihood then of disseminating 
tuberculosis and of infection. Adolescents may be considered in 
this same light. 

Huntington, of San Francisco, devised the following operation in 
1905: He opens the shaft of the femur with a half-inch trephine 
at the lower border of the great trochanter, tunnels through this open- 
ing, with a large curette, removing from the neck of the femur most 
of its cancellous interior till at a depth of two or two and a half 
inches the epiphyseal cartilage is encountered. It is generally 
desirable not to interfere with this, but if it be necessary to enter 
the head of the bone beyond, either at the time of operation or for 
the drainage of tuberculous foci in the femoral head and neck 
subsequently, a small curette should be used. This route had 
already been employed by Macnamara, of Dublin. The bone 
cavity should be packed with gauze. This is the most direct route 
for the removal of foci near the femoral head. Huntington recom- 
mends it both for osteomyelitis and for tuberculous disease. 

EXCISION OF THE HIP. 

A radiograph carefully studied in connection with the symptoms 
and signs should give us the best indication for excision of the 
hip, but skill and experience are necessary both to obtain satisfactory 
X-rays of this joint and to interpret them correctly. In England 
and Germany excision of the hip has been used to a far greater 
extent than in this country. 

Bardenheuer excised the acetabulum in twenty-six patients. 
The operation is a severe, not a fatal one, but it has not been done 
much in America. He considers it indicated in all cases of septic 
involvement of the acetabulum and acetabular caries where conserva- 
tive treatment has failed. His incision extends along the whole 
length of the crest of the ilium. All muscular attachments are cleared 
as far as the acetabulum. With a Gigli saw the acetabulum is sepa- 
rated from the ramus of the pubes, from its connection with the ilium, 
and the descending ramus of the ischium. It is easier to remove 



248 ORTHOPEDIC SURGERY. 

the acetabulum without opening the joint. If the head of the femur 
is also diseased it is sawed off at the neck. The wound should be 
closed with sutures and traction applied to the limb which is placed 
in an abducted position. As mutilation is great, a less useful 
limb may be expected than after simple excision of the head of 
the femur. 

Excision of the hip is performed through a curved incision over 
the trochanter from four to six inches long, commencing at a point 
midway between the anterior superior spine and the trochanter, 
exposing the trochanter and curving forward below it. As the inci- 
sion, deepened by careful dissection exposes the capsule and the tro- 
chanter, the tendons of the three glutei are divided, and the 
muscles lying in the line of incision are retracted, so that the 
capsule may be widely opened and the head turned out, the limb 
being flexed and rotated outward for this purpose. The head is sawed 
off with part of the neck. The muscular attachments to the posterior 
surface of the trochanter are then exposed by rotating the limb inward 
and the trochanter, if diseased, is sawed off. The neck is replaced 
in the acetabulum, the wound is partly sutured with drainage, the 
usual large aseptic gauze dressings are applied and a plaster bandage 
or Thomas hip splint used with traction in bed. During convales- 
cence a traction hip splint with slight abduction is needed for many 
months. 

During the operation the acetabulum should be examined, any 
sequestra removed and the carious surface curetted. If perforated, 
rough edges of the bone are removed freely. It is practically impos- 
sible to remove all the tubercular tissue in this operation. The ul- 
timate mortality from this operation at the Children's Hospital, 
Boston, and the Hospital for Ruptured and Crippled Children, in 
New York, is about 46 percent, the immediate fatality 7 percent. 
Rapid general miliary tuberculosis has been found in over ten per- 
cent. Excision of the hip is reserved for those cases in which mechan- 
ical treatment fails and where removal of extensive sequestra is neces- 
sary. It is a life saving measure. Useful limbs are secured, although 
the shortening is considerable, and the mechanical conditions are 
not conducive to the formation of a firm joint. In successful cases 



TUBERCULOSIS OF BONES AND JOINTS. 249 

a new joint is established and the neck of the bone becomes firmly 
attached to the ilium. A series of cases at the Children's Hospital 
four or more years after excision all walked without cane or crutch. 
Amputation should be a very last resort. Extensive amyloid 
degeneration or a moribund condition contra-indicates it. The 
mortality is slightly higher than in other amputations of the thigh. 



CHAPTER XVI. 

TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, 
ELBOW, WRIST. 

TUMOR ALBUS. 

Tuberculous disease of the knee-joint; white swelling of the 
knee, tumor albus; Scrofuloses Caries; Tuberculoses Caries; Tuber- 
culose chronique du genou; Tuberculose articulaire, etc. 

In considering hip disease and spinal disease we confessed the 
inability always to recognize tuberculous disease and to differ- 
entiate it from other chronic affections. Practically all chronic 
inflammations of the knee, however, which have typical symptoms 
and the course of a tumor albus, are considered tuberculous. 

White swelling of the knee is next in frequency and importance 
to hip disease. It interferes for a long time with locomotion and 
often results in permanent lameness; yet the prognosis is less serious 
both as to life and function of limb. The mechanical protection 
required to prevent deformity is a less difficult problem. 

Pathological Anatomy. — The disease is said to develop from a 
tuberculous infection either of the synovial membrane or of any of 
the bones forming the joint. Pathological evidence gathered hero 
shows that a primary synovial involvement must be very rare. It is 
needless to say that the view of the joint obtained at operation is mis- 
leading, that frequently primary foci of disease are only recognized 
in post-mortem specimens by carefully sawing the bones to pieces. 
Most pathologists now believe that the disease begins in the bone and 
involves the joint later. Either the femur or tibia may be involved, 
generally the patella is inflamed secondarily; however, tuber- 
culous ostitis of the patella alone has been reported four times by 
Gross; and 30 cases of primary tuberculosis of the patella have been 
gathered from literature. 

The disease occurs at all ages. The age of incipiency for 100 

250 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 25 1 

cases at the Hospital for the Ruptured and Crippled, New York, 
is as follows: 

One year or less, 2\ percent; 2 years, 4J percent; 3 years, 9 per- 
cent; 4 years, 16 percent; 5 years, 8 percent; 6 years, 7 percent; 7 
years, 7 percent; 8 years, 7 percent; 9 years, 6 percent; 10 years, 6 
percent; 11 years, 4 percent; 12 years, 2 percent; 13 years, 2 per- 
cent; 14 years, 2 percent; 15 years, 2 percent; 15 to 20 years, 5 per- 
cent; 20 to 25 years, 5 percent; 25 to 30 years, 3 percent; over 30 
years, ^'percent. 




Fig. 131. — Frontal section showing two tuberculous foci, one in each con- 
clyle. {Children's Hospital.) 



Boys are slightly more affected than girls, and the left knee more 
than the right. 

Symptoms. — The symptoms are pain, local heat, swelling, tender- 
ness, stiffness, spasm, restricted movement, atrophy, and distortions. 
Seeing the child walk stripped attracts attention both to lameness 
and swelling of the knee. It is a valuable part of the physical exami- 
nation. The enlargement at first may be slight, the surface about 



252 ORTHOPEDIC SURGERY. 

the patella and the subcutaneous outline of the condyles and the 
head of the tibia are always obscured. The surface temperature 
of the skin is slightly raised, the joint, sensitive to deep pressure, 
may contain a slight effusion and resemble simple synovitis. In 
most cases, however, the usual test for floating patella shows thicken- 
ing of the synovial membrane and capsule with but little fluid and 
the resistance under the finger is elastic, not liquid. The knee is a 
hinge-joint, the normal range of motion is from complete flexion, 
when the heel almost touches the buttock, to complete extension, 
180 or a little beyond that point. Slight impairment of motion at 
both ends due to reflex muscular spasm is present at the onset. 

The disease begins insidiously. Slight 
lameness and slight restrictions of mo- 
tion are the earliest signs and should 
always arouse suspicion of some sort of 
disease in the knee. As the swelling 
increases, palpation of the condyles and 
head of the tibia often shows a widen- 
ing on the affected side which can be 
verified by measuring the distance be- 
tween the condyles with calipers and 
comparing with a similar measurement 

of the sound knee. Complete exten- 
Fig. 132. — Acute flexion and . i? . 1 1 1 • -i 1 

characteristic swelling and S10n of the knee becomes impossible 
atrophy. because it brings more pressure on in- 

flamed bone, and so we find little by 
little, flexion setting in with increasing stiffness and attacks of 
pain, the flexed knee becomes hot, tender, and sensitive to jar. 
As the bone inflammation in children begins in the epiphyses of 
the femur or tibia and near the joint surface of the patella, it has 
but a little way to travel to reach the joint, and it is, therefore, 
common for an invasion of the joint to come early. 

After the joint cavity is involved it contains more fluid, the skin 
is hot, movements are much more restricted by spasm, the atrophy 
of the muscles of the thigh and calf is marked, and shortening may 
be present to a slight degree or it may not be noted till later, al- 





TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 253 

though lengthening sometimes occurs from overgrowth of the epiph- 
ysis produced by inflammatory hyperemia in the neighborhood of the 
epiphyseal discs, and it may measure one-half inch longer than 
the other. Such overgrowth limited to one condyle adds knock- 
knee deformity. Knee flexion, however, makes it difficult to estim- 
ate this. Pain is not severe usually, exceptionally night-cries 
are a prominent symptom from the same cause as in hip disease. 
Malpositions of the limb result from the greater power of the ham- 
string muscles in the flexed position of the knee. This is not due so 
much to the size of the muscles as to the direct mechanical advantage 
of their line of pull. Flexion of 
the knee is a distressing symp- 
tom and one which is trouble- 
some even late in the convales- 
cent stage. The hamstring pull 
produces in time a backward 

displacement of the tibia, called FlG - 133— Extreme flexion deformity 
,,.... . . of left knee. 

subluxation 01 the knee joint, 

associated with external rotation of the tibia, or eversion, and 

usually with knock-knee which may be unrecognized until the limb 

is straightened. 

Abscesses are not uncommon. They may be cold abscesses, pure 
tuberculous ones, or they may start as cold abscesses and then become 
invaded by pyogenic organisms. 

Diagnosis. — The diagnosis is easily made from the history of 
lameness, the peculiar enlargement, restriction of motion from 
muscular spasm, increased surface heat, and slight continual eleva- 
tion of the body temperature. Owing to its superficial position, 
the knee is easy to examine. The radiograph is an aid to a precise 
knowledge of the lesion. By aseptic aspiration and inoculation in 
a guinea pig, the diagnosis of tuberculosis can be established. 

Prognosis. — The outlook for a useful limb is excellent if protec- 
tive treatment be early begun and faithfully persisted in. More 
or less stiffness of the knee is usual but a number of children have 
been known to recover with full normal motion and little short- 
ening. Cases coming for treatment after long periods of neglect 



254 ORTHOPEDIC SURGERY. 

can only expect to recover with deformity and disability. Some 
cases are very severe from the start; there is danger of permanent 
deformity in these. 

TREATMENT OF TUMOR ALBUS. 

The treatment should include general treatment, conservative 
treatment, radical treatment, and symptomatic surgical treatment. 

General Treatment. — Under general treatment the same atten- 
tion should be given to increased feeding, abundance of fresh air 
for long periods, and general hygiene as described in chapters on 
hip disease and spinal disease. 

Conservative treatment or local treatment is directed toward 
fixation and protection of the joint. Effective fixation may 
be obtained by a snug plaster bandage from toes to groin; 
short plasters from the middle third of the leg to the upper third 
of the thigh are manifestly inefficient. In some cases, however, the 
softness and fleshiness of the thigh renders a leg plaster inefficient; 
then a plaster spica extended to the toes fixes the knee. One 
must prevent the body-weight from resting on the affected limb. 
This can, of course, be done by recumbency or by means of a thick 
sole under the sound limb and crutches under the arms so that the 
limb swings clear of the ground, or a splint may be used as a perineal 
crutch. The ischiatic crutch of Judson, though designed principally 
for hip disease, is a good splint for this object. Better still, the 
Thomas knee splint. (Chapter XXI, page 373.) This splint can 
be used as a means of fixing the knee in a straight position by 
adding a leather knee-cap and straps combined with a broad 
leather band behind the knee to prevent forcing the joint into hyper- 
extended positions. The calf and thigh should be steadied by broad 
leathers laced. During the stage of convalescence, when spasm 
has disappeared but the limb still needs to be protected against 
sudden falls, the Thomas knee splint may be converted into a caliper 
splint by cutting off the foot piece and bending the ends to fit into 
a metal tube in the heel of the shoe. The splint should be too 
long for the heel to touch the ground. Blisters, and brushing with 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 255 

the Paquelin cautery are useful as counter-irritants and to relieve 
pain temporarily. 

Bier's treatment by passive hyperemia and dry heat is, according 
to that author's statement, of great benefit to some patients and of 
very doubtful utility to others. 

Resection of Knee-joint. — We have already referred to the 
early location and removal of tuberculous foci in the hip. For the 
removal of these, resection of the knee-joint is not advised in young 
children because it produces excessive shortening from destruc- 
tion of the epiphyseal cartilages; seven-eighths of the growth of the 
limb comes from the epiphyseal cartilages nearest the knee-joint. 
The knee-joint is, however, superficial, and the interior of the con- 
dyles of the femur and of the tibia are within easy reach of the sur- 
geon's trephine or chisel. Starr, of Toronto, has reported excellent 
results from this method of treatment. 

Operations for Early Removal of Foci. — Bernard Bartow, 
of Buffalo, recommends the following operation: An incision, 
about 2 inches long, is made through the skin, on the lateral 
aspect of the condyle, exposing the capsular ligament and pe- 
riosteum freely enough to use the ordinary trephine — three-quar- 
ters of an inch; the periosteum and the margin of the capsular 
ligament are elevated together and reflected before trephining or 
removing a button with the gouge; the bone is then penetrated with 
a small sharp curette in search of a softened diseased area; when 
the curette enters it, the operator has a sensation of penetrating a 
cavity. The diseased tissue lies usually on the distal side of the 
epiphyseal disc and it may reach to the articular facet of the bone. 
It is surrounded with condensed bone on all sides. Bartow, after 
thorough curetting, swabs with a 25 percent solution of zinc chloride 
on a cotton pledget, after which the bone cavity is flushed with 
1-2000 bichloride, and filled with 10 percent solution of tincture of 
iodine, or strong carbolic acid in glycerine, and part is allowed 
to remain. The periosteum and skin are sutured separately. The 
operation is not indicated if the joint is invaded. 

Moorhof, of Vienna, has used his absorbable bone-filling in a 
similar operation with excellent results (see page 193). The perios- 



256 ORTHOPEDIC SURGERY. 

teum is tightly sutured over the filling and the wound closed without 
drainage. Flexion is relieved by dividing the hamstring tendons 
unless their contraction disappears during etherization. 

The end results, as regards motion in the knee, are excellent in 
Bartow's cases. 

Drainage of the Knee. — Operative surgical interference is neces- 
sary in severe cases, either to evacuate pus or to correct deformity. 
General rules applicable to abscess about the hip are to be followed 
here also, and frequent examinations by radiographs should enable 
the surgeon to act more intelligently as the presence of a superficial 
abscess may be a sign of extensive destruction of the interior of the 
condyle of the femur or of the tibia. 

Arthrectomy. — For the relief of persistent flexion and abscess which 
is rarely found except as the result of neglect, the joint has frequently 
been resected, and Oilier, of Lyons, devised the operation of arthrec- 
tomy or erasion of the joint. The destructiveness of these bone- 
abscesses about the knee is sometimes appalling; they are doubtless 
mixed infections. After breaking into the joint and from the joint 
into the surrounding tissues, the greater part of the thigh and leg 
may be invaded. 

The operation of arthrectomy of the knee is performed by making 
an incision similar to that for resection of the knee-joint, extending 
from the external to the internal condyle, just below the patella, 
dividing the skin, the superficial and deep fasciae, the capsule, the 
anterior portion of the lateral ligaments and ligamentum patellae. 
By flexing the knee and dividing, if necessary, the crucial ligaments, 
the joint surfaces of the femur and tibia are freely exposed, and with 
a sharp Volkmann spoon the eroded articular surfaces may be 
opened into, and as much of the softened cancellous interior removed 
as possible. It is often feasible in this way to remove all the cancel- 
lous bone in the epiphysis of a child. 

Tuberculous abscess walls may be freely curetted or treated with 
strong carbolic, and alcohol, with tincture of iodine, or with nitrate 
of silver solutions. The ramifications of the abscess in the thigh 
should be thoroughly explored and drained, after which the joint 
should be replaced in a straight position and the patellar ligament 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 257 

securely sutured with kangaroo tendon, silver wire or silk worm gut. 
The joint should be sutured except at the sides where drains are 
placed; counter-openings into abscess ramifications should also 
be wicked. 

While this operation in the hands of the writer has usually been 
attended by secondary septic infection beginning two weeks or 




Fig. 134. 

more afterward and while in some cases there has been shock, the 
results have been good. That is to say, the children got well with 
a stiff straight knee and with little shortening, after several 
months of suppuration, during which conservative treatment seemed 
far more dangerous to life than amputation. 



CORRECTION OF FLEXED KNEE. 

Permanent flexion of the knee may be remedied mechanically or 
by operation. Traction may be used in bed by the apparatus shown 
in Figure 134. It may also be applied by means of the Thomas 
17 



258 ORTHOPEDIC SURGERY. 

knee splint (Chaper XXI, page 373). With the patient walking about? 
the splint may be bent at an angle less than the angle of his deform- 
ity. Traction is made upward above the knee by adhesive plasters 
attached to the thigh, and buckling on to the splint. Downward 
traction is made by plaster extensions below the knee attached to 
a ratchet and pinion traction bar at the bottom of the splint. 
Leather lacings for the thigh and calf fix the splint tightly to the 
limb. By means of the perineal ring the patient's weight is 
borne on the splint, and from time to time the gain may be com- 
pensated for by straightening the splint at the knee. 

Plaster Bandages to Correct Flexion. — This method is applica- 
ble to flexion of short duration. During the acute stage or during 
exacerbations they should be applied to the knee without attempting 
to extend it, and changed once a week as it will often be possible 
to straighten a little at each successive application, the principle 
involved being complete rest with locomotion without weight-bearing. 
Forcible straightening may be done under ether, and if adhesions 
are absent, spasm overcome by anaesthesia permits immediate straight- 
ening unless subluxation is present. Adhesions may be broken up 
by manipulating the joint in various ways. The following method 
has been devised by Whitman, of New York, for resistant cases, 
especially if accompanied by a slight degree of luxation. 

Forcible Straighening under Anaesthesia. — The patient, anaesthe- 
tized, is placed face downward on a table, with the feet projecting 
over its end. The body and hips are raised on a pillow until the 
thigh allows the shin to lie evenly on the table on a folded sheet. 
The operator with one hand holds the head of the tibia firmly 
against the table and with the other massages the contracted 
tendons of the popliteal space, exerting more and more down- 
ward pressure on the thigh but never allowing the shin to lift 
from the table. Little by little as the knee straightens the pillows 
are withdrawn. The deformity is often reduced in one sitting, 
but if very resistant incomplete correction is attained the first 
time, adhesive plaster straps for traction and a close fitting plaster 
bandage are applied, in order that the rest in bed with traction 
may be maintained. This method employs the body-weight of the 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 259 



child's trunk to reduce the subluxation under ether. The correc- 
tion under full anassthesia of subluxated knees may also be accom- 
plished by the genuclast of Bradford and Goldthwait. The apparatus 
resembles a great iron tuning fork with a screw pad four inches 
below the tips of the branches. The leg is put between the 
branches with the calf resting on the screw pad; and counter 
pressure is got from leather straps 
passing over the knee and leg pro- 
tected by thick saddler's felt which 
allows great force ot be exerted by the 
screw without danger of pressure sores. 

Adhesions may first be ruptured by 
forcible flexion. The apparatus is then 
put on the limb in a flexed position and 
the head of the tibia pushed forward 
as far as possible, and by lifting the 
end of the appliance which serves as a 
handle, the leg is then extended slowly. 
The forward pressure on the head of 
the tibia can be increased from time to 
time and the pressure on the knee 
altered if necessary by loosening the 
straps. Adhesions of the patella con- 
tra-indicate its use. 

Operations to Correct Ankylosis 
with Flexion. — When excision is done 
for angular ankylosis, the only modifi- 
cation which is necessary is the removal , FlG - I 3.5- — Subluxation of 

knee straightened without re- 
of a wedge-shaped bit of bone of proper ducing deformity. A bad result. 

size to allow the approximation of the 

sawed edges so that angularity is obliterated exactly. 

Osteotomy of the femur just above the condyles has also been 
employed for the correction of flexion with ankylosis. By this means 
the straightened leg is healed with the lower end of the femur almost 
at a right angle to its shaft so that the lower extremity of that bone, 
when viewed laterally, looks like a golf club. The more nearly the 




260 ORTHOPEDIC SURGERY. 

tibia lies in line with the femur the more security there will be in 
walking. 

Ollier's operation of arthrectomy may be used instead of excision 
for the correction of angular ankylosis; it is only to be preferred to 
excision for children, because it is easier to avoid injury of the epiphy- 
seal discs when removing small bits of bone with the chisel and 
curette, than it would be with a saw. The risk of operative tuber- 
culous infection is, of course, less in correcting old ankylosed joints. 

Amputation of the thigh is seldom necessary, and only as a life- 
saving measure. 

Excision is a last resort preferable, perhaps, to amputation for 
cases in which conservative treatment has failed or where the disease 
is too extensive and the general health is failing. It is a far better 
operation for adults, where it is an excellent operation to correct 
flexion caused by bony ankylosis. The mortality between the 
ages of five and twenty is less than 10 percent. Ankylosis is the 
aim of the operation but it is not always attained and there is a tend- 
ency to flex in some even where ankylosis has apparently been secured. 
The technic of the operation is described in all the books on general 
surgery and is therefore omitted here. 

TUBERCULOUS DISEASE OF THE ANKLE-JOINT. 

Tuberculous disease of the ankle-joint comes next in frequency 
to that of the knee. It is frequently associated with tuberculosis 
of the hip, knee or spine. It is common in little ones, and has been 
known under the names of strumous or scrofulous disease of the 
ankle, caries of the ankle, and chronic ankle-joint disease. 

The pathology of the affection does not essentially differ from 
that of hip disease, but the small bones of the tarsus are in early 
childhood largely cartilaginous and their destruction may be rapid 
and complete. When this condition can be localized in a single 
tarsal bone by the radiograph, time may be saved by a complete 
extirpation of that bone. 

Abscess is even more frequent here than in other forms of bone 
tuberculosis. Gibney found it in 83 percent of his cases, Prendles- 
burger in 87 percent. This is probably explained by the super- 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 26 1 

ficial position of the bones of the tarsus, which makes a small abscess 
apparent, whereas in the knee and hip it may often be overlooked 
if small because it is deep-seated. Owing to this superficiality 
an abscess may break before the process of re-absorption really begins. 
The affection includes both disease of the small tarsal bones and 
disease of the lower part of the tibia and fibula. 

Symptoms. — Lameness comes early and the limp is a marked 
one, one may be lame from pain or from stiffness. Swelling is soon 
noticed, a boggy infiltration over the affected bone or over the ankle- 
joint, which is early invaded by tuberculous granulations. This 
invasion of the ankle-joint produces a swelling restricted sharply 
by the anterior annular ligament and the lateral ligaments of the 
ankle, so that a bulging is seen in front of and behind the malleoli. 
Pain and tenderness on pressure or on joint motion may be present ; 
swelling and heat are always present. Muscular spasm is also 
marked at the limits of motion, and joint motion is much limited. The 
swelling is more diffuse if an abscess be there for then the depres- 
sions from the ligaments disappear and the ankle and foot become 
uniformly swollen. 

The usual malposition is an equino valgus from muscular spasm 
which relaxes under ether or when joint irritation is over. Atrophy 
of the thigh and calf accompanies it. The restriction of ankle motion 
is less, the farther away from the real ankle the disease is, e. g., if 
the os calcis is diseased the ankle-joint often escapes. A history of 
preceding trauma is not infrequent. 

Diagnosis. — In childhood the affection is only liable to be con- 
founded with sprains, and chronic sprains are ever suspicious in 
children. In fact in children any chronic painful disease, associated 
with a slight rise of temperature and confined to a single joint whose 
motion is limited by muscular spasm which is held in malposition, 
is tuberculous almost ninety-nine times out of a hundred. 

In adults, infectious and rheumatoid arthritis, gouty arthritis, 
and cancer may be hard to differentiate. The X-ray is of great 
value and should be used both for diagnosis and to watch the prog- 
ress of tuberculous invasion. 

Prognosis. — Excepting in neglected cases or where the disease 



262 ORTHOPEDIC SURGERY. 

has been attended with excessive and prolonged suppuration, the 
prognosis in children is very good under conservative treatment. 
A serviceable foot, even after extensive suppuration and destruction 
of bone, is most always the result. The prognosis is somewhat 
better when the astragalo-tibial joint is not invaded. Conservatism 
is less good for adults. 

The writer has, however, recently had under observation a patient, 
81 years of age, in whom this affection had lasted less than a year. 
Conservative treatment had been employed and apparently with bene- 
fit. Bone destruction was slight; two small abscesses had left sinuses 
and one of these had closed. The radiograph showed evidence 
of the commencement of the healing process. This illustrates the 
fact that conservatism may be useful in adults. 

General treatment is as important as it ever is in tuberculosis. 
As a rule, however, the use of crutches and sticks, plaster bandages, 
or iron splints has allowed the child with ankle disease to retain 
almost the activity of a healthy child. Hygienic surroundings, 
abundance of fresh air, very generous and nutritious feeding, should 
be used to sustain the general health. 

Local treatment involves fixation by plaster bandages and pro- 
tection from weight-bearing. Fixation should be complete in the 
acute stages, but a little restricted motion of the foot may be allowed 
at other times. Protection from weight-bearing may be accom- 
plished by a high sole and crutches but it is more efficacious to use 
the Thomas knee splint. (See Chapter XXI, page 373.) 

Abscesses are more apt to break here and less apt to absorb; 
therefore, they fall more frequently under the surgeon's knife than 
do cold abscesses of the hip. There exists, however, the same 
danger of infection from the operation or subsequent dressings, 
either from tuberculous or necrotic matter left behind or from sepsis 
introduced from without. An X-ray should be taken before operat- 
ing to detect the presence of necrotic bone. Where this is absent 
a small incision without further disturbance is best. 

Excision of a Tarsal Bone. — Where a single tarsal bone is largely 
destroyed by disease, it should be removed entire. Otherwise, 
necrotic bone or softened bone should be removed with a sharp 



TUBERCULOSIS 01 KNEE, AXKLE, TARSUS, SHOULDER, ETC. 263 

Volkmann spoon, if in the os calcis; in other parts of the tarsus, 
this procedure is less satisfactory. Before removing diseased bone, 
the surgeon should consider whether the disease will be arrested by 
the procedure or even if it will be benefited. As a rule, partial 
operations, gouging and scraping, are far more harmful than the 
complete excision of the bone, which can often be removed leaving the 
periosteum. Sub-periosteal resection of the lower epiphysis of the 
tibia and astragalus has been successfully performed. 

Excision of the Ankle. — The writer prefers the route of Kocher 
for excision of the ankle. The patient, anaesthetized, lies on the 
face with the outer side of the foot up, a curved incision is made 
along the outward border of the foot just below the external malleo- 
lus reaching from the extensor tendons to the tendo Achillis. The 
peroneal tendons are found in their groove and divided, after attach- 
ing two silk guides, between which they are cut. The external 
lateral ligament is divided and the joint opened freely by twisting 
the foot inward so that it is entirely dislocated and both joint sur- 
faces can be inspected to any extent and offer a fair field for removing 
whatever is best. After accomplishing this the foot is reduced to 
its proper position, the lateral ligament sutured, the peroneal ten- 
dons united, and the wound closed with superficial sutures. A 
small sterilized dressing and plaster bandage is then applied with 
the foot in a correct position. Heavy dressings and prolonged immo- 
bilization in the same plaster are used for two months to insure 
complete repair of the ligaments and tendons. After excision, 
weight-bearing should be prevented for eight or nine months by the 
Thomas knee splint. Amputation is rarely if ever needed in children, 
and finds its chief utility in young adults who cannot afford to lose 
many months from their business. 

Dactylitis in the foot, disease of the metatarsal bones and the 
phalanges, is considered in text-books on general surgery and will, 
therefore, be omitted. The protection from weight-bearing is essential. 

TUBERCULOUS DISEASE OF THE SHOULDER-JOIXT. 

Tuberculosis of the shoulder is an insidious chronic affection 
prone to suppuration and eventually resulting in a stiff joint. It is 



264 ORTHOPEDIC SURGERY. 

fortunately not common. Young found tuberculosis of the shoulder 
in y~q percent of orthopedic hospital cases. The disease is often 
associated with disease of other joints. It may begin at any 
age. The primary focus is in the head of the humerus usually, 
but the scapula may be diseased separately or in conjunction 
with it. A few cases were supposed to originate in the synovial 
membrane. 

Symptoms. — The pain is distressing — a dull, aching pain, worse 
at night, referred to the shoulder or the middle of the humerus; 
there is tenderness in small areas anterior or posterior to the joint; 
the arm is instinctively kept quiet; passive motion evokes muscu- 
lar spasm; the humerus and scapula move together; the joint 
contour is changed early from atrophy of the deltoid and enlarge- 
ment of the head. Looked at from above the joint looks wider in 
an antero-posterior direction and flatter externally. Natural de^ 
pressions are obliterated. Suppuration often leads to complete 
destruction of the head of the humerus with, in time, ankylosis and 
a weak and often much shortened arm. 

Treatment demands the same general building up as in all 
forms of tuberculosis. Local treatment is very unsatisfactory. 

The weight of the arm gives traction to the joint in the erect posi- 
tion. Abscess usually leads to prolonged suppurating sinuses. 

Excision oj the joint is often necessary both in adults and children. 
In adults it is the operation of choice as soon as the diagnosis is 
indisputably established. It may be excised through an anterior 
incision or a posterior one. The periosteum is divided with a bone 
knife along the inner border of the bicipital groove. The arm 
rotated outward and inward allows the ripping up of the periosteum 
and the muscular attachments as they appear. The Gigli saw is 
used to remove as much of the bone as is diseased, after the head 
of the bone has been thrown out of the wound. Fixation can be 
obtained by strapping the arm to the side with a thick pad between 
body and arm. A light plaster-of-Paris bandage including the arm 
and chest affords thorough fixation. Late excisions when the 
joint has been distended with pus, perforated, and many sinuses have 
developed, are practically impossible to free from tuberculous material 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 265 

at the time of operation. The use of iodine, carbolic acid, or alcohol 
is here desirable and some drainage should be maintained. 

Amputation is only a life-saving measure as the more conserva- 
tive operation of excision accomplishes almost the same thing. The 
disease may last for years. 

TUBERCULOUS DISEASE OF THE ELBOW JOINT. 

Tuberculous disease of the elbow-joint is almost as common in 
childhood as disease of the ankle. Girls are more frequently affected 
than boys; no one knows why. 

Koenig gives the ages as follows: 

Under 10 years, 25 percent; 10 to 20 years, 20 percent; 20 to 30 
years, 12 percent; 30 to 40 years, 15 percent; 40 to 50 years, 8 per- 
cent; 50 to 60 years, 14 percent; 60 to 70 years, 6 percent. 

Symptoms. — The primary focus is generally in one of the bones, 
the ulna originating almost one-half. Tuberculous ostitis here is 
usually in the olecranon or close to the epiphyseal line, that is to 
say, close to the articulation with the humerus, hence joint abscess 
or the invasion of the soft parts about the joint is frequent. The 
forearm cannot be extended, but flexion, pronation, and supination 
are free in the early stage, and the surface temperature is often 
increased. Swelling may begin at the side of the tendon of the tri- 
ceps. Wasting of the arm and forearm shows early; stiffness pro- 
gressively increases; movements are limited by muscular spasm; 
the joint is usually held at an obtuse angle; starting pains by day 
and night-cries may become the source of great discomfort ; the swell- 
ing generally-fusiform may grow very large; areas of fluctuation 
appear; sinuses follow; the whole region about the elbow becomes 
pulpy in untreated cases or in those which relapse; limitation of 
rotation of the forearm arouses suspicion of tuberculosis in the 
head of the radius. 

Prognosis is for eventual recovery with a stiff elbow unless con- 
servative treatment be maintained from the start or a successful 
excision be done. 

General treatment should be employed as for tuberculosis else- 
where. 



266 ORTHOPEDIC SURGERY. 

Local Treatment. — Fixation is best furnished by plaster-of-Paris 
or molded leather, frequent removals and re-adjustments disturb 
and injures the joint. A sling to be worn properly should support 
the hand as well as the arm. The elbow should be flexed, if possible, 
to a right angle, to insure a useful position of the arm, should anky- 
losis occur. The rest afforded by successive plaster bandages, 
changed every two or three weeks, may be sufficient to secure the 
right-angled position, for rest will quiet muscle irritation and spasm. 

Excision oj the Elbow. — If the disease be progressive, excision 
or arthrectomy are to be preferred to conservative treatment, but 
in early childhood, cures with a better range of motion are 
obtained without operation. Excision is also indicated for ankylosis 
in malposition. Excision is done through a posterior incision about 
5 inches long with the olecranon in the center, — a longitudinal 
incision which is carried down to the bone. Periosteum and soft 
parts are lifted from the humerus by a periosteal elevator; the bones 
are dislocated; the periosteum is removed from the humerus ante- 
riorly and its articular end sawed off. The same is done to the 
proximal ends of the radius and ulna. In childhood, as little 
material should be removed as possible and yet leave no tuber- 
culous bone. Iodine, carbolic acid, or alcohol may be used if the 
ramifications of the abscesses and sinuses cannot be easily excised. 
Thorough fixation which will allow change of dressings and the 
early abandonment of wicks may be secured by immobilization 
of the arm and hand and the application of a plaster bandage which 
is bivalved. If the muscles and ligaments are not badly damaged, 
passive motion may begin in three weeks, but the immobilization must 
be maintained for months with daily slight movements given and con- 
trolled by the patient. The fatality of the operation is very slight. 

Kocher obtained cure in 96 percent of his cases, and two-thirds 
of his patients could use the arm for hard work. Koenig's results 
were less satisfactory, and those at the Children's Hospital, in 
Boston, also are less satisfactory. 

Excision of the elbow is done to cure ankylosis in malposition. 
The after-treatment is the same. In many cases where it is shown 
by the radiograph that foci are small and isolated, partial resections 



_ 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 267 

devised to suit the individual case are often of great benefit. Brad- 
ford says that passive motion is undesirable, as a rule, except in 
adults who have been operated upon for ankylosis or comminuted 
fracture and whose ligaments have been well preserved during 
operation. A movable elbow in childhood after resection is too apt 
to mean a weak flail joint. 

TUBERCULOUS DISEASE OF THE WRIST-JOINT. 

Tuberculous disease of the wrist, metacarpus and phalanges is 
considered in text-books on general surgery, and does not differ 
materially from tuberculosis of other joints. 

Wrist disease is attended by swelling, heat and stiffness. The 
hand is flexed and the joint is enlarged. In destructive disease 
the forearm and hand are swollen and suppuration occurs often, 
motion is limited by spasm, muscular atrophy is present, the skin 
over the wrist is usually hot. 

Diagnosis is usually easy and the radiograph of great assistance. 
Fixation in splint or plaster and carrying the arm in a sling is recom- 
mended. 

Excision of the joint is indicated for children who, under conser- 
vative treatment, get progressively worse, and in adults whenever 
the disease is destructive. 

Passive Hyperemia Treatment for Tuberculosis. — In the knee, 
ankle, elbow, and wrist, the treatment of tuberculous disease by 
venous stasis or by enclosing the limb in a chamber from which 
the air is exhausted has been extensively tried by Bier and Klapp, 
in Bonn. The application of a rubber constricting bandage was 
first made; only lately has suction treatment come into vogue. 

At first constriction by a turn of rubber bandage above the joint 
was used only for one or two hours a day or twice a day; if swelling 
took place, treatment was abandoned until it disappeared. Cold 
abscesses appeared, they grew rapidly; fistulae sprouted large masses 
of granulations and some joints had acute exacerbations of pain 
and tenderness, and this treatment was not well thought of. How- 
ever, good results were obtained in one tuberculous shoulder 
where the hyperemia had been maintained for daily periods of 



268 ORTHOPEDIC SURGERY. 

twelve hours. It was then tried for long periods of time, producing 
rapidly an edema which became chronic and so excessive that the 
treatment had to be abandoned in a few days. Pauses were made 
between periods of treatment sufficient to allow this edema to sub- 
side and the following precautions are now taken by Bier. 

Hyperemia should never be allowed to cause pain. If it does it 
is used wrongly. The bandage should be changed if it makes the 
limb cold, the skin should be as warm as that of the other limb. 
Hyperemia for seven to twelve hours a day certainly reduced the 
tenderness and pain in the joints. After this had been accom- 
plished the period of hyperemia was gradually diminished until 
often several weeks or months had elapsed, when it was used for 
only one hour a day. Edema was found only in the first days of 
treatment. By elevating the limb between treatments it would 
disappear. Cold abscesses then appeared as infrequently as usual, 
they did not increase rapidly, and they were drained early; com- 
plicated dressings were avoided, and sinuses were never wicked. 
Under this treatment, the following good results were reported by 
Bier: 17 cases of wrist-joint disease, 4 of which presented fistula? 
at the beginning of treatment, 5 others had abscesses opened during 
treatment, all had useful motion and 3 perfect motion at the con- 
clusion of treatment. No deformity resulted although subluxa- 
tion of the wrist and complete stiffness of fingers and hands had 
been present. Two had many abscesses. In wrist-joint disease, the 
duration of treatment by hyperemia was usually about twelve months. 

Elbow- joint Disease. — Eleven cases treated; 5 of them with fistula? 
at the beginning of treatment; 8 required incision for drainage of 
abscesses of whom 2 still have fistulae. Normal motion was never 
secured but a useful amount of motion was present in all. The 
average period of treatment was nine months. 

Tuberculous Disease of the Foot. — Thirteen cases were treated; 8 
of them with fistulae at the beginning; in 6 abscesses were drained; 
8 cases were well, 3 improved, 1 not improved, and 1 was amputated 
outside of the clinic. The average period of hyperemia treatment 
was ten months. Full mobility of the ankle and foot was obtained 
in 3 cases, and a useful position for walking in all. 



TUBERCULOSIS OF KNEE, ANKLE, TARSUS, SHOULDER, ETC. 269 

Tuberculous Disease of the Knee-joint. — Five cases were treated, 
2 with abscesses, i with fistulae; 3 cases were cured and 2 were improved; 
2 had full motion of the knee, and 1 was stiff but in good position. 
The 2 improved cases had a stiff knee; 8 more cases after short 
periods of hyperemia treatment underwent resection. 

Tuberculous Disease of the Shoulder-joint. — One case, which 
healed with normal mobility. 

The worst results have been observed in the knee, where resection 
of the joint was necessary 8 times out of 13. There seems to be no 
regularity in the results. The best results are found in tuberculosis 
of the wrist and hand. 

Suction Apparatus. — Klapp has. recently, instead of using the 
constricting bandage, placed the limb or joint in a glass vessel from 
which the air was exhausted; by this means hyperemia is established. 
He confined himself to cases with abscesses or fistulae. This hyper- 
emia can be localized over the tuberculous areas if they are super- 
ficial, but not if they are deep and far distant, as is the case in caries 
of the spine. The most convenient appliance for a fistula is a 
cupping glass with a bulb to exhaust the air. 

The form of cupping glass must be altered to suit the part of 
the body but a few different shapes are sufficient. The glass is 
rendered aseptic by soaking in a 1-1000 corrosive sublimate solution. 
The method of application is not different for bones, glands, or 
other forms of tuberculosis. At first, the cup should be applied 
for three-fourths of an hour every day; after it has been applied for 
five minutes, it should be taken off for three and reapplied, and it 
should not be used beyond a point when pale, flabby, tuberculous 
granulations change into red, tough ones. At that time the treat- 
ment should be changed from daily to once every three to eight 
days. The results in those with fistula? and abscesses, Klapp thinks, 
are better than with passive hypernia from the bandage. In order 
to secure adaptation of the cupping glass it is necessary to cleanse 
the skin with benzine and apply lanoline or vaseline to the edges of 
the glass. This is removed from the skin with benzine as soon as 
the glass is taken off. 



CHAPTER XVII. 

DISEASES OF BONES AND JOINTS FROM DISORDERED 
NUTRITITION. 

SCURVY. 

Scurvy, scorbutus, is a constitutional disease from malnutrition; 
its usual cause is deprivation of fresh food. 

The symptoms are anemia, ecchvmoses and subcutaneous hemat- 
omata from slight causes, bleeding under the mucous membrane 
of the mouth or from the gums. This bleeding from the gums 
comes from a stomatitis ulcerosa and occurs frequently when there 
are teeth; it is a necrobiosis in the mucous membrane and tissues of 
the gums at the borders of the teeth. 

In infants scorbutus has followed the use of many of patented 
infant foods and has also occurred occasionally in those who were 
fed on sterilized milk. 

In 379 cases of scurvy reported to the American Pediatric Society, 
swelling in or about the joints was observed in 45 percent; and rick- 
ets was present in 45 percent. No special microorgansim has been 
found to cause scorbutus. 

Pathological Anatomy. — The pathological changes are hemor- 
rhages under the skin, in among the muscles or tissues surrounding 
the joints, occasionally into the joints themselves, but the hemor- 
rhage is of tener under the periosteum of the long bones. The long bones 
of the arm and leg are most frequently the seats of this subperiosteal 
hemorrhage. Interstitial hemorrhages in the lungs, spleen, kidneys, 
and intestinal glands, and hematuria have been observed. Separa- 
tion of an epiphysis from the shaft may occur from this bleeding in in- 
fancy. The common age for scorbutus in childhood is from eight 
to fifteen months. 

Diagnosis. — Clinically they have swellings of the leg and fore- 

270 



DISEASES FROM DISORDERED NUTRITION. 271 

arm bones which are very tender to pressure but there is no increase 
of surface temperature, and ecchymoses appear in the skin and 
around the gums and lining of the cheek. 

Rotch observes that the mucous membrane of the gums is affected 
only when teeth are present or a tooth is coming. The infant keeps 
the affected limb or limbs perfectly stiff to avoid painful movement, 
a condition called pseudo-paralysis, as his tenderness is then extreme. 
It is easily differentiated from rickets but the two conditions may 
occur together. Purpura Jacks the subperiosteal hemorrhages. 
Pain is present only occasionally on the first day of an acute infantile 
paralysis and there are no large ecchymoses. Hemorrhage into 
into the joints and under the periosteum has led to an erroneous 
diagnosis of osteomyelitis or acute arthritis of infancy which it may 
resemble except for the absence of fever. Hence, free incision has 
been made through the periosteum, the blood was under such high 
tension that the whole shaft of bone immediately popped out. A 
new tibia grew later from the periosteum. In some cases a knee- 
joint may be full of blood, and much swollen. When subperiosteal 
hemorrhage alone is present, there is a swelling of the shaft just 
above the epiphysis. 

Ridlon, and Taylor have described cases of scorbutic disease 
in the vertebrae. Acute pain in one case had been present for 
three weeks; passive movements of the legs caused crying; even 
rolling the child over in bed gave extreme suffering; the spine arched 
forward and was held rigid throughout its entire length. With 
appropriate diet the child was well in two weeks. No swellings 
were found in the thighs, legs or forearms, and no elevation of 
temperature. This condition is probably more common than is 
realized. 

Treatment in these cases should be conservative and medical. 
Babies should be kept on a pillow, and painful movements avoided. 
The essential thing is to change the food to a diet of fresh milk and 
orange juice. Orange juice for the baby is what lime juice is for the 
sailor. Babies should be given the juice of one orange a day and if 
improvement does not rapidly take place, two oranges a day should 
be given. 



272 ORTHOPEDIC SURGERY. 

RHACHLTIS, RICKETS. 

Rhachitis or rickets is a disease of impaired general nutrition which 
is common among the children of strangers or those not yet 
acclimated. Acute rickets comes in the early years of life, the time 
of the most rapid growth of the skeleton. Improper feeding and 
unhygienic surroundings predispose to it, it may begin after pro- 
tracted diarrhoea, vomiting, bronchitis, or broncho-pneumonia. 
Fetal rickets has been described but its existence is doubtful; late 
or adolescent rickets occurs but is uncommon. Rickets frequently 
attacks a whole family of brothers and sisters, but it is not known to 
be hereditary. The character of the disturbance of nutrition on 
which it depends is unknown. Boys and girls are equally affected. 

The following table of ages has been compiled from various 
authors by Rotch:- 

First year, 37y\ T percent; second year, 44^; third year, i2, 4 (T ; 
fourth year, 2^; fifth year, i T 4 ^; over five years, i T 4 ^ percent. 

It is essentially a disease of the temperate zone; and flourishes best 
in cold, moist climates: it is unknown both in arctic and tropical 
and is rare in subtropical countries. It is also uncommon in high 
altitudes. It is exceedingly common in all classes of life, more so 
than was formerly supposed, especially in large seaboard cities. 
Morse found that 80 percent of the patients at the Infants' Hospital, 
in Boston, under two years of age, showed some of the bone changes 
characteristic of rickets. Softness and bending of the bones in 
rickets may be generally distributed or localized. It may come in 
breast-fed infants but as it is rare during the first six months, this 
may be accounted for by the deterioration in the quality of the 
milk after the first six months of lactation. 

Pathology. — The principal lesions of rickets are those in the 
bones. The bones normally grow in length by the production of 
bone tissue between the epiphysis and shaft; in circumference, by 
a growth of bone from the inner or osteogenic layer of the perios- 
teum; the endosteum also forms bone. Cancellous bone formation 
between the epiphysis and shaft is retarded and abnormal, in rickets. 

An irregular overgrowth takes place there which causes an apprecia- 



« 



DISEASES FROM DISORDERED NUTRITION. 273 

ble enlargement, but the tissue of this overgrowth is not bone but os- 
teoid tissue, a soft yielding tissue consisting of a hyaline matrix and 
cartilage cells slightly altered but not transformed into bone cells, a 
tissue which never ossifies and grows most irregularly so that the 
line between the shaft and epiphysis is wavy and irregular and the 
juxta-epiphyseal region is much widened and thickened. The 
osteogenic layer of the periosteum is also much thickened, the cells 
are large, juicy, and irregularly arranged, and instead of de- 
positing hard concentric layers of lime and new bone cells, there 
is formed partly osteoid tissue, partly cartilage, and partly true bone. 
The bone is weak because new bone ceases to form, it is also eaten 
away to a varying degree from within by the action of the giant cells 
(osteoclasts) which pass in along the Haversian canals and also 
attack the walls of the general marrow cavity. It is not surprising 
that such bones bend or break, or that the region where the epiphysis 
joins the shaft enlarges. Owing to bone absorption by the giant 
cells the medullary cavity enlarges, the cortical bone is thinned and 
weakened and partly replaced by soft osteoid tissue and so allows 
the bone to bend under the strain (pressure) from body-weight or muscle 
pull. Enlargement of the spleen and liver are usually noted. Spon- 
taneous fractures have sometimes occurred and they are often not 
recognized except by the X-ray. 

The deformities of rickets which the orthopedic surgeon sees 
are coxa vara, bow-legs, knock-knees, flat-foot, curvature of the 
spine, deformity of the chest, and a few deformities of the arms. 

COXA VARA. 

Coxa vara is a frequent rhachitic deformity. Its treatment is 
the same as non-rhachitic coxa vara (see chapter X, page 145). 

BOW-LEGS. 

Bow-legs, genu varum, genu extrorsum, out-knee, bandy legs, 

Sabelbein, Sichelbein, O-bein, genou en dehors. Bow-legs may 

represent an outward lateral or a forward bowing of the thigh, the 

leg, or both. A bowing curve of both thighs and legs produces the 
18 



274 



ORTHOPEDIC SURGERY. 



outline of the letter O, hence the German name O-bein. It is the 
commonest of all rhachitic deformities. In Children's Hospital, in 




■■« 







Fig. 136. — Anterior bow-legs — in addition to curves it shows that the 
enlargement is in the shafts next to the epiphyses; not in the epiphyses. 
(Children's Hospital, A. W. George, Radiographer.) 



Boston, bow-leg is present in about 13 percent of the orthopedic 
out-patients, and it is more often double than single. 



DISEASES FROM DISORDERED NUTRITION. 



275 



Bowing of the Femur. — Bowing of the shaft of the femur usually 
has the convexity directed outward and forward. There is thicken- 
ing of the bone where it bends on the concave side. In extreme 
cases the medullary cavity is narrowed or bridged over. Spontan- 
eous straightening by growth has often been observed with restora- 
tion of proper relations at the knee. Usually the whole shaft bends 
evenly but many cases are seen where the lower end of the shaft is 
bent sharply with forward convexity. Femoral bowing may be 
produced by ankylosis of the knee in a bent position, and these low- 
seated bends are sometimes neutralized by a sharp bend of the tibia 
just below the head. 

Bad deformity of the thigh may demand osteoclasis or osteotomy, 




Fig. 137. — Adult bow-leg. Tibia showing adaptive thickening of cortex. 
(Warren Museum.) 

followed by overcorrection in a plaster spica for three months; 
during the last month, however, the patient is allowed to walk in 
his plaster bandage. As the curvatures of the thigh are apt to recover 
if left to themselves, this operation is seldom performed on children 
under seven or eight years old. 

Bowing of the Tibia and Fibula. — The bow-leg deformity usually 
has its seat in both tibia and fibula, and the curve may be lateral 
or antero-posterior. The most frequent point of curvature is at 
the junction of the middle and lower third of these bones. A child 
with lateral bowing stands with the legs apart and the deformity is 
plainly seen as he walks in the street; his gait is a waddle, the 
body leans at each step and the child usually toes in. If coxa vara 



276 



ORTHOPEDIC SURGERY 



co-exists abduction is restricted and the equilibrium is adjusted 
by keeping the knees partly flexed. It is very unusual to have any 
pain. 

Diagnosis. — The diagnosis is evident on inspection. In little 
babies the tibia may seem slightly curved when it really is not, or 
they may be bowed without rickets. These usually get well un- 
aided in a few months. To estimate the amount of bowing 
in the femora the legs should be crossed until the inner condyles 
are in contact, when the deformity of the thighs becomes evident 
Although it is well known that bow-legs are frequently outgrown, 

there are no data on which to 
form an opinion as to the 
chance of outgrowing the de- 
formity in a given case. 

Treatment.— With suita- 
ble treatment, mechanical or 
operative, any child can be 
permanently cured, and in 
adults the bow-legs may 
always be improved by opera- 
tion. Anterior bow-leg is not 
amenable to mechanical treat- 
ment but is readily cured by 
operation. Some think that 
operative treatment in small children should be postponed because 
of their liability to relapse, owing to their soft, yielding bones; 
sufficient hardness may be expected when the tibia has grown 
to a length of seven inches. During the period of expectant treat- 
ment a tracing of the outline of the leg should be taken once a 
month and compared with the previous one to watch for increase 
or decrease of the deformity. Walking should be discouraged. 
Thrice a day the mother should grasp the ankle in one hand and 
press upon the point of greatest deformity with the other endeav- 
oring to straighten the leg; or the child should sit with the ankles 
touching and the legs be pressed together by the flat of the mother's 
hand. Tracings are made (Fig. 138) by seating the child with legs and 




Fig. 138. — Tracing of bow-legs. 



DISEASES FROM DISORDERED NUTRITION. 277 

hips bare on a piece of paper sufficiently large, placing the ankles 
and great toes in contact, while the surgeon with a pencil, always 
kept vertical, marks the outline. Up to four years of age, braces 
may benefit bow-legs. See Chapter XXI for braces. 

They should be worn day and night or a special night brace may 
be used in bed. When sufficient improvement has been secured, 
they may be discontinued by degrees. 

Operation is indicated in children who are old enough, and even 
for slight deformity in anterior bow legs. 




Fig. 139. — Bradford's modification of the Rizzoli osteoclast. 

Osteoclasis consists in breaking, setting and holding a leg as 
for a simple fracture. The break should be made at the point of 
greatest curvature. The operation may be performed by the hands 
of the surgeon, bending the leg over a folded sheet on the edge of the 
table. But this requires unusual manual strength and an osteoclast 
is usually employed. Osteoclasts of various kinds have been devised. 
That of Rizzoli is, perhaps, most commonly found in hospitals. 
A. Meyers, Heusner, Grattan, R. T. Taylor, Keen, and Bradford, 
have recently devised excellent osteoclasts. Speed in the use of the 
osteoclast prevents pressure sores and its exact control in the hands 



278 ORTHOPEDIC SURGERY. 

of the operator is the safeguard against compound fracture. All 
osteoclasts break efficiently near the middle of a bone. The 
points of counter-pressure should be over the end of the shaft, as it 
is otherwise possible to separate an epiphysis. After osteoclasis 
the leg is put in plaster, straight or slightly overcorrected. Rotation 
of the foot is also corrected and a properly padded plaster-of-Paris 
bandage is applied from the toes to the groin to be worn from eight 
to twelve weeks. 




Fig. 140. — Keen's osteolast. {Children' s Hospital.) 

Osteotomy is to be preferred whenever the point of greatest curvature 
is near the end of the diaphysis or when a marked anterior or antero- 
lateral bowing presents any peculiar features which might make osteo- 
clasis difficult. Cuneiform osteotomy is unnecessary and produces 
shortening. In severe, sharply localized curves the removal of a 
wedge may be avoided by driving the chisel into the concave side of 
the bone, incompletely dividing it and opening up the bone care- 
fully in straightening with the hands, so as to leave an unbroken 
attachment. No incision is necessary for linear osteotomy. The 
chisel or osteotome (a chisel sharpened like a simple wedge less 
than one-half inch wide) is driven through the skin parallel to the 
axis of the bone until the edge engages; then it is turned at right 



■B 



DISEASES FROM DISORDERED NUTRITION, 



279 



angles to the shaft and with light blows driven into the bone, dividing 
first the upper, then the lower edges of cortical bone and partially 
dividing the side of the bone away from the operator; the fracture 
is completed by the surgeon's hands. Both the fibula and tibia 
should be partially divided before attempting fracture. The small 
incision made by the osteotome bleeds very little. 
It is dressed with sterilized cotton, the limb en- 
veloped in cotton wadding and a plaster bandage 
applied as after an osteoclasis. 

Anterior bow-legs may be corrected either by 
osteoclasis or osteotomy. The osteoclast is applied 
to the side of the leg so as to locate the break at 
the point of greatest curve, otherwise the sharp 
anterior ridge of the tibia may perforate the skin 
under the pressure of the osteoclast. It is desir- 
able to perform subcutaneous tenotomy of the 
tendo of Achillis so as to prevent recurrence of the 
deformity, because the soleus and gastrocnemius 
act strongly like the string of a bow. In anterior 
bow-legs osteotomy should aim to divide the pos- 
terior, inner and outer surfaces of the shaft with the 
osteotome, leaving the ridge of the shin to be broken or bent by the 
hand. This prevents any displacement of fragments and shortening, 
but demands some skill in the use of the osteotome. 




Fig. 141. — Anter- 
ior bow legs. 



KNOCK-KNEE. 



Knock-knee; in-knee; genu valgum; genu intorsum; X-Bein; 
Bacherbein; genou en dehors; genou cagneux; ginnocchio valgo. 
Knock-knee means inward prominence of the knee, the femur and 
leg bones, forming an angle with each other, opening outward. It 
is about one-half as frequent as bow-legs at the Children's Hospital, 
in Boston. It is rarely congenital, but sometimes arises from fracture 
or separation of the epiphysis, from infantile paralysis, or follows 
bone disease, tuberculous osteitis or osteomyelitis; nevertheless 
most cases are from rickets. They may be one-sided or double or 



28o 



ORTHOPEDIC SURGERY. 



we may have a knock-knee with a bow-leg on the opposite side. 
Unilateral cases may show shortening of the limb from distortion, 
a one-sided lowering or obliquity of the pelvis and lateral curvature 
of the spine from limping. Knock-knees are easily sprained; 
they have pain and are much impeded in their gait. By abducting 
and rotating the hip outward, they swing the knees around each 
other in walking, in a clumsy fashion, to prevent knocking. Both 
thigh and leg bones may be bent. Flat-foot and pigeon-toe fre- 
quently accompany it and the median side of the boot heel is 

always more worn than the outer. 
The bending of the femoral shaft is 
in the frontal plane and twist of the 
shaft of the tibia is often associated. 
This twist is in the direction of the 
outward rotation of the foot. The 
patella in severe cases lies over the 
external condyle. Boys are more 
frequently affected than girls; and it 
comes on sometimes during adoles- 
cence and is due to adolescent 
rickets. Coxa vara frequently co- 
exists with knock-knee. Slight de- 
grees of knock-knee are normal in 
women and in a few men. If a 
child cannot stand with his knees 
touching, his ankles together and 
his toes pointing forward, he has 
knock-knee. 

There exists in knock-knee as in 
bow-legs a tendency to spontaneously outgrow the deformity, 
although no definite data have been accumulated to prove this 
statement. Severe ones cannot correct themselves. Moderate cases 
in young children are amenable to mechanical treatment, and slight 
cases in little, rapidly growing children may be cured by manipula- 
tion and general treatment. Even the severest cases are corrected 
by operation. 




Fig. 



142. — Knock-knees. 
drew' s Hospital.) 



(Chil- 




DISEASES FROM DISORDERED NUTRITION. 251 

TREATMENT. 

Treatment. — In babies and little children, tracings may be 
taken and compared once a month, while daily manipulations of 
the extended knee are tried and may straighten. Infants 
learning to walk may need a support for the arch of the foot, and if 
so the inner border of the sole of the boot may be raised one-quarter 
of an inch. If they do not improve, treatment by mechanical appli- 
ances becomes impera- 
tive. The knock-knee 
splint (see Chapter XXI) 
pulls the knee outward 
to an upright on the 
outer side of the leg and 
also keeps it extended, 

for the deformity is 

Fig. 143. — Manipulation to straighten 
greatest in the extended knock-knee. 

position. A night ap- 
paratus should also be used. Mechanical treatment is seldom suc- 
cessful after four or five years of age. 

Osteotomy is the operation of choice in this country, although in 
Vienna and in Italy artificial separation of the epiphysis, epiphyseoly- 
sis, is much used. Macewen's osteotomy is a linear division across 
the lower extremity of the diaphysis of the femur, it is used even when 
the X-ray shows the seat of the deformity in the tibia. Schede, 
and Blanchard, of Chicago, however, have used linear osteotomy of 
the tibia and fibula in such cases. Macewen's osteotomy has been 
singularly free from fatalities. It is performed by driving an oseo- 
tome into the femur on the inner side of the thigh at a point just 
above the tubercle for the adductor magnus tendon. Incision 
is unnecessary, for the osteotome is driven in at right angles to the 
shaft and the femur is divided in the same manner as the tibia for 
bow-legs; the fracture is completed by the hands and the subsequent 
treatment is similar to that following osteotomy for bow-legs. The 
plaster bandage extends from the waist to the toes. 

Epiphyseolysis. — This operation is a straightening by partly 



282 



ORTHOPEDIC SURGERY. 



separating lower epiphysis of the femur and must be limited to those 
who have not yet united the epiphysis to the shaft. It has been used 

extensively in Austria and Italy; 
Reiner has his patient lie on the 
side with the leg to be operated 
on uppermost, he puts the inner 
condyle on a block of wood firmly 
clamped to the edge of the table 
about five inches high and a little 
lower at the edge of the table; he 
uses this block as a fulcum, bring- 
ing the leg down so that the sup- 
port stops three-quarters of an 
inch above the widest point on 
the condyles, he completely ex- 
tends the knee, grasps it with the 
palm over the patella and with 

the forearm over the fibula 
Fig. 144. — Bow-leg and knock-knee. . . .. 

presses downward upon it with 

slowly increasing force till the deformity is straightened. The edge 
of the fulcrum should be opposite the epiphyseal disc. A plaster 
spica bandage is applied and the after-treatment is like that for 
correction by osteotomy. Codivilla bends it over the 
edge of the table, Lorenz bends it in his osteoclast. In 
children who are still undergoing the softening of rickets 
an infraction occurs, not a separation of the epiphysis, 
and therefore this procedure should be limited to the 
years between eight and eighteen. The presence of a 
disc of cartilage is essential, so adolescents should be 
X-rayed to make sure of its presence. 

Splint Treatment. — The gradual correction of knock- 
knee by apparatus is restricted in this country to chil- 
dren less than four years old. In 





Fig. I45-— 
Diagram of 



Germany, Julius Macewen's 
Wolff, of Berlin, uses for older children the corrective 
plaster bandage. Wolff first applies a plaster bandage from the toes 
to the groin holding the knee as straight as he can while it sets. After 



DISEASES FROM DISORDERED NUTRITION. 



283 



three days the bandage is divided by a circular cut around the knee, 
he removes a wedge-shaped piece from the inner side so as to allow 
further straightening of the deformity and approximation of the edges 
of the cut. While the leg is held in this position, more plaster bandage 
is applied around the knee and allowed to harden so as to maintain 
the gain. This process is repeated 
every three days until a slightly over 
corrected position is reached. The 
same bandages are worn for three or 
four months. It is necessary that the 
bandage be applied fairly tight espe- 
cially at the top and bottom. After 
complete correction has been obtained 
broad hinge joints can be incoporated 
in the plaster so that the knee may flex 
without a return of the knock-knee de- 
formity. A portion of the foot should 
be in the bandage. Wallace Blanchard, 
of Chicago, prefers osteoclasis to epi- 
physeolysis for the rapid correction of 
knock-knees, he uses the Grattan oste- 
oclast and brings the point of fracture 
not far from the place selected by 
Macewen for osteotomy. Incomplete 
fracture or osteokampsis (green-stick 
fracture) may sometimes be accom- 
plished by this means. 

FLAT-FOOT. 
Rhachitic flat-foot requires no differ- 
ent treatment from that of static flat- 
foot. See Chapter X. 

RHACHITIC SCOLIOSIS. 
The rounded kyphos of acute rickets may demand recumbency 
for a few months. 
Rhachitic scoliosis has been considered in chapter VII, page 105. 




*IG. 146. — Lateral curvature 
from knock-knee of rickets. 



284 ORTHOPEDIC SURGERY. 

RHACHITIC DEFORMITIES OF THE ARM. 

The principal deformities of the arm consist in conditions of the 
elbow similar to knock-knee and bow-legs, in-elbow and out-elbow. 
Unilateral deformities of this sort may in rare instances give rise to 
scoliosis. This danger is an added argument in favor of correcting 
this deformity. In-elbow means that the hand and arm hangs by 
the side while the elbow is separated from it and objects cannot be 
carried at full arm's length without striking the leg. Attempts to 
obviate this produces a leaning to the side and eventually scoliosis. 

Osteotomy has frequently proved of great benefit by correcting the 
deformity and straightening the arm. Peckham, of Providence, 
reports that a cure of scoliosis resulted. In little children the deform- 
ity may be watched by tracings as is done for bow-legs and knock- 
knees. Manipulations should first be employed. It is well not to 
operate too young as the deformity is sometimes outgrown like bow- 
legs. 

RHACHITIC FRACTURE. 

Patients are occasionally seen whose rickets during the acute 
stage differs from those cases usually described in our text- 
books. The bones are, in the early years of life, unusually plia- 
ble, and children have been characterized by their crossness, and 
ill temper. If these cases be studied with the X-ray, the bones are 
found to be deficient in lime salts, very transparent, and frequently 
unsuspected fractures and partial fractures are detected. A case 
of this sort was described by Feiss and a recently taken X-ray 
negative showed the same condition in a child three and one-half years 
old, at the Children's Hospital. This condition borders upon 
osteogenesis imperfecta, osteomalacia, and rickets. 

OSTEOMALACIA. 

Osteomalacia is uncommon in America. Its occurrence in child- 
hood is comparatively rare even in places where it abounds. In 
adults it follows pregnancy. Osteomalacia is a nutritional disorder 
of bone characterized by a great decrease in the lime. 



DISEASES FROM DISORDERED NUTRITION. 



28$ 



Pathology. — The pathology is still in dispute. Virchow believes 
that a solution of the lime salts of bone occurs, like the chemical process 
by which bone is decalcified in acid. Cohnheim, that the organic and 
inorganic constituents are destroyed by giant cells called osteoclasts 
and are replaced by new osteoid tissue free or comparatively free from 
lime. Von Recklinghausen found osteoblasts and islands of true bone 




Fig. 147. — Osteomalacia girl of fifteen: Dr. Painter's patient. 
{House 0} Good Samaritan.) 



in the osteoid tissue described by Cohnheim. The affection weakens 
both the compact bone of the shaft and the spongy bone of the ends 
of long bones. It is a general process throughout the skeleton. 
Goldthwait, Painter, Osgood and McCrudden found that bone of 
osteomalacia differs from normal bone in its chemical composition, 
being poor in lime and rich in magnesium, and in its relative propor- 



286 ORTHOPEDIC SURGERY. 

tion of organic substances; it contains much sulphur and but little 
phosphorus. (It is somewhat similar in chemical composition to the 
normal organic matrix of bone.) McCrudden analyzed two ribs of 
a horse affected by osteomalacia and compared their analysis with 
that of two normal horse ribs. He showed a decrease in the calcium, 
an increase in the magnesium, an increase in the sulphur and a 
decrease in the phosphorus present, and the inorganic material 
of bone as a whole is greatly decreased. These softened, thinned 
bones bend and break easily, producing great deformity. After 
breaking a callus forms which may or may not solidify. The dis- 
tortions are most irregular. The back is bowed, the chest flat- 
tened and the arms and legs are much twisted. 

The treatment has been so far unsatisfactory. Fehling, in 
Germany, has cured many adults by ovariotomy, as he considers 
the affection a tropho-neurosis of bone, due primarily to diseased 
ovaries. Other surgeons, however, like Neumann, assert that ova- 
riotomy does not materially affect the process; that the ovary is not 
always diseased, for the condition occurs in children before functional 
activity of the ovary begins, also in boys and men. That this treat- 
ment may mask for a time loss of calcium is probably all that can 
be claimed for juvenile cases. In puerperal osteomalacia, however, 
Fehling certainly had excellent results. Medication has offered no 
encouragement. Careful estimations of the ingesta and excreta 
have been made by McCrudden, showing an excess of calcium oxide 
in the excreta over that ingested. Possibly some dietary treatment 
may be evolved. 

The Spine. — The pathological anatomy of the spine in osteo- 
malacia has been described by Schulthess in JoachimsthaFs Hand- 
book of Orthopedic Surgery. There is marked increase in dorsal 
kyphosis, a slight increase in the lumbar lordosis, and frequently 
lateral curvatures. These changes are accompanied by marked 
lateral compression and increased downward obliquity of the ribs, 
with a flaring lower border of the thorax resembling Hutchinson's 
furrow of rickets and a flaring outward of the wings of the ilium 
and distortion of the pubic rami. The intervertebral discs are 
large in the center and the individual vertebrae markedly hollowed 



DISEASES FROM DISORDERED NUTRITION. 287 

to accommodate them. Schulthess found much less deformity 
than usual in the skeleton of a patient who was early bed-ridden 
as if weight-bearing were the essential factor in deforming the spine. 

OSTITIS DEFORMANS. 

Ostitis deformans, described by Paget, in 1877, is also known 
as Paget's disease. It is essentially an affection of later adult 
life in which the bones enlarge, soften, and become unnaturally 
curved and misshapen. It is a combination of a rarefying and a for- 
mative growth of bone and it attacks the shafts of the long bones, 
the spine and the skull. Arteriosclerosis is so often associated with 
it that it has been deemed its cause and arthritis deformans may 
accompany it. The skull may be greatly enlarged and thickened. 
Rheumatic pains and headaches occur early in the disease but some 
never have pain, the general health is not affected. The attitude 
is characteristic; the bowed legs, well apart, support a rounded back 
and an enlarged head. The gait is clumsy and stiff, and the head 
droops forward toward the chest. The joints are not affected! 
Fractures are uncommon, and when they occur they unite readily. 

In a series of twenty-five cases reported by R. B. Osgood and E. 
A. Locke, it was found that the average period of onset was between 
43 and 44 years. Radiographs show both abnormal density and an 
increased thickness in the shafts of the long bones and in some places 
one finds obliteration of the medullary canal. In the leg, the long 
bones are bowed; in the arms they are not. The spine is usually 
bowed, more or less rigid and lateral curvature of moderate degree 
may develop. No satisfactory treatment has been formulated. 

Treatment. — For the relief of quasi-rheumatic pain, which is 
probably due to a combination of arthritis deformans and ostitis 
deformans, Peckham recommends superficial cauterization once a 
month, and half-way between times the application of a blister on 
the side of the spine over the painful area. 

Goldthwait thinks anything which increases the circulation dimin- 
ishes pain; hot water, hot air, simply wrapping the parts in flannel 
or cotton, or gutta percha tissue may relieve pain. 



288 ORTHOPP2DIC SURGERY. 

Peckham believes that in some cases its progress has been arrested 
by counter-irritation. 

SECONDARY HYPERTROPHIC OSTEOARTHROPATHY. 

This disease was first described by Marie, in 1890, since which 
time many cases have been reported. It comes as a complication of 
pre-existing chronic disease of the lungs, often developing in the 
train of pneumonia with delayed resolution. The deformity is a 
hypertrophy and an exaggerated clubbing of the fingers and nails 
and effusion into some of the joints. The hypertrophy seems to 
be caused by a deposit of layers of bone under the periosteum of 
the metatarsals, metacarpals, and phalanges, and in the distal ends 
of the bones of the forearms and legs. In a few cases, the femora 
humeri, and spine, as well, have been enlarged. It begins painlessly, 
with clubbing of the terminal phalanges and hypertrophy of the 
finger-nails. When the wrists and ankles become large pain and 
tenderness to pressure develop and it has been mistaken for a mild 
attack of rheumatism. But little is known of the nature of the disease, 
although the cause may be the absorption of toxins, from the pri- 
mary disease, and that the hypertrophy may be analogous to amy- 
loid enlargement of the internal organs in long-standing suppurative 
disease of the bones. The condition may become less marked, or, 
according to Whitman, may disappear if the patient recovers from 
the original disease of the lungs. It is very uncommon in childhood. 
Whitman records a case of complete recovery following the cure of 
Pott's disease and chronic bronchitis — the hypertrophied phalanges 
alone remaining. Although secondary hypertrophic osteoarthropathy 
may be due to the irritating presence of toxins, it may also be due 
to some disorder of nutrition. 

ACROMEGALY. 

Acromegaly a condition of hypertrophy or unnatural enlarge- 
ment of the hands, feet, fingers, toes, lower jaw, lips, etc., may resemble 
osteoarthropathy but the involvement of the face and head should 



DISEASES FROM DISORDERED NUTRITION. 289 

discriminate between them. The patients are often giants, with 
enormous hands and feet, and large, dull faces. 

Sternberg divides the disease into three forms: First, the slight 
form where the changes are slight and the duration of the disease 
may be 50 years; second, the chronic form has marked growth 
of head, hands and feet and a duration of from 8 to 30 years; third, 
the acute or malignant form, has a duration of 3 or 4 years only. 

After a period of growth a cachexia and muscular atrophy come on, 
cardiac dilatation and weakness render the patient very helpless, 
there are frequent nose-bleeds, and death usually is by syncope. 
Arthritis deformans has been observed in the early stage of acromeg- 
aly. The giants are not infrequently round shouldered and scolio- 
tic. This condition is supposed to be due to disease of the pituit- 
ary body and is analogous to myxoedema from the thyroid gland. 
The pituitary is often sarcomatous. 

CHARCOT'S DISEASE OF THE JOINTS. 

Charcot's joint disease is a destructive form of arthritis secondary 
to locomotor ataxia, but it may also be found with syringomyelia. 

The articular cartilage becomes eroded, degenerates and wears 
away by the movements of the limb. The underlying bone is exposed 
and wears away, and meanwhile an exaggerated, irregular formation 
of cartilage and bone takes place about the periphery of the joint 
which is rarely distended with fluid. The capsule and synovial mem- 
brane are hypertrophied and may contain calcareous plates. 

The knee is the joint most frequently involved. The hip, foot, 
and shoulder come next. Only 15 cases of tabetic spines have been 
reported. About one-quarter of the patients whose large joints 
are affected have joint disease of both knees, both hips, etc. 

Pain is usually insignificant. The chief complaint is of weak- 
ness and insecurity; the progress of the disease is often rapid. 

The diagnosis may be difficult when it is an early symptom of 
locomotor ataxia, as it may arise before the existence of tabes is 
suspected. 

Arthropathy of the vertebra) has been studied by Spiller, of Phila- 
19 



290 ORTHOPEDIC SURGERY. 

delphia. It is characterized by a deformed position of the spinal 
column, lateral curvature and backward bowing. Some relief 
of pain may be expected from fixation in a plaster-of -Paris jacket. 

The process in the hip is characterized by the acute onset of 
extensive joint changes; the synovial effusion is at times very great, 
a large fluctuating tumor presenting both at the front and the back 
of the joint, with crepitus from wearing away of the articular car- 
tilage of the head of the bone; either spontaneous dislocation occurs 
or a migration upward such as is found in late hip disease. 

Treatment consists in efficient support to prevent progressive dis- 
tortion, while the underlying nervous affection must receive atten- 
tion. Powerful galvanic currents have been recommended by Weir 
Mitchell to stimulate re-absorption of the effusion. Repeated 
aspiration of the joint sac accompanied by rest to the joint has been 
advised. Traction in bed may give relief from pain. 

ARTHRITIS DEFORMANS. 

Arthritis deformans, rheumatic gout, rheumatoid arthritis, dry 
arthritis, osteo-arthritis, chronic rheumatism, malum senile, etc. 

These terms have been used to describe chronic joint processes of 
unknown etiology which had this in common, that they were not tuber- 
culous. Little is known of their etiology except that Schueller iso- 
lated a bacterium from the fringes of some cases and afterward 
claims that it is only causative of part of the cases of arthritis defor- 
mans. Goldthwait divided rheumatoid diseases into five groups 
or diseases, chronic villous arthritis, hypertrophic arthritis, atrophic 
arthritis, infectious arthritis, and chronic gout. For the sake 
of simplicity let us assume that the term infectious arthritis 
must include not only the majority of what is called arthritis defor- 
mans but also many other joint inflammations; it should not only 
be classed by itself but it should include all the different joint diseases 
produced by a specific infection with different microorganisms. 
Chronic gout also belongs in gout rather than here; and villous 
arthritis can be neither a disease nor a variety of a disease, for it only 
refers to joints which have undergone a peculiar proliferation of the 



DISEASES FROM DISORDERED NUTRITION. 291 

synovial membrane, a proliferation which occurs as the result of 
trauma, of many well-known diseases of the joints both nutritional 
and neuropathic like tabes, and inflammatory like tuberculosis 
and gonorrhoea. 

If now one excludes from the list of Goldthwait infectious arthritis, 
villous arthritis, and chronic gout, there remain the hypertrophic 
and the atrophic arthritis which are here called two types of the old 
arthritis deformans, because although clinically they may be dis- 
tinguished, they are usually at post-mortems associated in the 
same individual, when they may either represent an association of 
two different diseases or different stages of one and the same 
disease. 

THE ATROPHIC TYPE. 

In the atrophic type one has to do with a progressive, 
painful joint affection attacking first the knuckles which are dis- 
tended with a moderate effusion, the capsule thickened, and the 
articular cartilages thinned; slowly the cartilage disappears, the bone 
atrophies to a thin shell, the peri-articular tissues even the skin, 
wastes; owing to loss of cartilage the joint grates if moved: in time 
the bone becomes so thin that one side of the joint telescopes to some 
extent into the other producing deformities and partial dislocations; 
the final result is a small atrophied joint; but the disease is progres- 
sive and chronic and though it may stay in a single joint several 
months, it always extends to many joints before it stops spreading 
which it does not do for many years. The cause is unknown. 
Either a large joint or the knuckles begin the trouble and fingers 
are always affected very early. It is recognized most readily by 
the small crepitating joints. Goldthwait considers the prognosis 
good under efficient treatment. Others say that the disease pro- 
gresses uniformly and slowly from bad to worse. In some it comes 
to a standstill and after awhile they become much better. 

Treatment. — Locke and Osgood consider the open-air treat- 
ment indicated which one gives a tuberculous patient, preferably in a 
sunny, mild climate, living and sleeping out of doors. Anemia, mal- 
nutrition, nervous debility, obesity or emaciation should be corrected, 



292 



ORTHOPEDIC SURGERY. 



a search be made to discover any suppurative process and cure 
it anywhere in the body; cardiac and renal trouble must receive 
appropriate treatment. Locally, massage and joint movements, 
active and passive, to prevent fibrous ankylosis, and rest during pain- 
ful attacks.^ Corrective operations may be needed to restore loco- 
motion lost through contractions of knee or ankle, manipulations 
under ether or tenotomy, three weeks in plaster for the ankle, six for 

the knee. A flat-foot plate is often 
needed after manipulating the ankle 
and caliper splints to walk in after the 
plasters on the knee. In reducing knee- 
flexion the greatest gentleness is desir- 
able lest the joint be irritated and 
made painful. 

THE HYPERTROPHIC TYPE. 

The hypertrophic form is described 
as " either a local or a general process 
characterized by thickening at the 
edges of the articular cartilages or at 
the attachments of the ligaments, form- 
ing ridges or nodes which become ossi- 
fied and interfere in varying degrees 
with joint motion." It is a chronic 
inflammation of unknown cause char- 
acterized by a growth of osteophytes 
on the borders of the joints. The 
bone becomes very dense at the end, 
the articular cartilages may be absorbed or thinned where the 
joint surfaces press upon each other, but unlike the atrophic form 
the articular cartilage is thickened at the periphery. The osteophytes 
w r hich appear about the dorsal and lateral aspects of the knuckles 
are known as Heberden's nodes. Osteophytes around a joint may 
limit its motion considerably; but there is little pain unless pressure 
be made on a new forming osteophyte. When the osteophytic enlarge- 
ment presses on a nerve passing over it there is very severe pain. 




Fig. 148. — Spondyliti's defor 
mans of Lovett. 



DISEASES FROM DISORDERED NUTRITION. 293 

In the spine, osteophytes grow from the antero-lateral attachments 
of intervertebral discs chiefly, and often seem to ossify the anterior 
common ligament on one or both sides; a beginning process 
produces a lipping of the vertebrae. The costo-vertebral articula- 
tions are sometimes involved. In the knee, shoulder, etc., the cap- 
sule and synovial membrane undergo chronic thickening and villi are 
present and a membrane of organized fibrin extends over the cartil- 
age, forming a pannus and the cartilage beneath it disappears 
while in the periphery the cartilage is thick and osteophytes grow. 

The treatment consists in preventing joint irritation during the 
period of active growth of osteophytes. This is accomplished by 
giving rest to the joint. Braces, splints, or plaster-of-Paris, may 
be used for this purpose. 

Where less complete fixation suffices, strapping or a flannel ban- 
dage gives relief. Prolonged rest seems to round off the sharp exos- 
toses, to reduce the hypertrophy of the cartilage, and produces in some 
a return of painless joint motion. Osteophytes are occasionally 
removed to relieve pain or to increase the range of joint motion, but 
pain is apt to recur. When acute attacks of pain are not relieved by 
rest, venous stasis, or sweating with rubber tissue, or the hot air 
baking may do good. Peckham, of Providence, recently reported 
that the electric light bath was efficacious to relieve pain. 

The general health is little affected. Therefore, internal treat- 
ment is unnecessary. 

ARTHRITIS DEFORMANS IN CHILDHOOD. 

Still's disease but lately was considered a tuberculous affec- 
tion. The process starts at or before the period of second den- 
tition; it is polyarticular, usually fever free, at times associated 
with enlargements of the lymphatic glands and spleen, it is 
characterized by the gradual onset of joint stiffness and swell- 
ing, but it may, however, come on acutely with fever, and chills. 
Girls are affected more frequently than boys. It is an uncommon 
disease. Several joints become stiffened and enlarged from a 
thickening of the capsule and swelling of the soft tissues outside 



294 ORTHOPEDIC SURGERY. 

of the joint; muscular atrophy is pronounced; there may be profuse 
sweating; the skin may be shiny and easily acquires pressure sores; 
secondary anemia may be present. 

The disease is incurable but at times an arrest occurs. Children 
with long-standing Still's disease are apathetic, listless, and 
emaciated; the skin sometimes has a brown color, suggestive of pro- 
found toxemia. After periods of joint enlargement lasting a year 
or more, a gradual subsidence takes place and the joint function 
usually is entirely restored; but, meanwhile, other joints have been 
affected. 

In the patient from whom the illustration was made, the dis- 
ease had been present for two years. The following joints were 
affected: i toe; 2 ankles; 2 knees; 1 hip; 1 shoulder; 1 elbow; 
2 wrists; 3 ringers; other fingers had been and the swellings had 
entirely disappeared. Aspiration of a joint resulted in the withdrawal 
of cnly a few drops of clear fluid; no bacteria were found in it; later 
on, the swellings over the ankles were incised and small portions of 
the peri-articular tissues were removed and examined but no bacteria 
were found; the tissues were edematous and resembled a myxoma- 
tous tissue. 

Cases seen early are often benefited by massage and baking. Pas- 
sive motions during the massage are better than too much exercise. 

GOUT. 

The joints of gout are probably irritated by the presence of poi- 
sonous substances generated through imperfect tissue metabolism, 
not by bacteria or their toxins, but it must still be regarded as a disease 
of unknown etiology. 

Gout is a constitutional affection, characterized by acute inflamma- 
tory processes in the joints, which may be followed by chronic inflam- 
matory changes and the deposit of masses of urate of sodium in 
the cartilages and around the joints. Twinges of pain in the small 
joints of the hand and foot are premonitory symptoms, but an acute 
attack comes suddenly with extreme pain usually in the bunion joint 
of the big toe which swells rapidly and is hot, tense, and shiny. It 



DISEASES FROM DISORDERED NUTRITION. 295 

seems as if it were in a vice. The temperature may rise to 102 
or 103 . Pain never goes away but is worse at night for from five 
to eight days, when tbe symptoms gradually abate. Other joints 
may be involved subsequently, often the corresponding toe of the 
other foot is. Some have three or four attacks a year, others at 
long intervals; with increasing frequency and with the gradual 
involvement of other joints, chronic gout becomes established. 
Deposits of urates appear in the articular cartilages, ligaments, and 
peri-articular tissues, and in time the joints of the feet and hands 
become irregular and deformed. Concretions may also be found 
about the elbows and knees, the tendons and bursae; the skin may 
ulcerate and the chalk-stones be exposed and disintegrate. This 
disease is rare in America but irregular gout may be more frequent 
than was formerly believed to be the case; and occasionally at 
autopsy deposits of urate of soda are found in the joints of those 
who, during life, were supposed to have arthritis deformans. 

This case was reported by F. L. Richardson, of Boston, in a 
clinical report of 75 cases of arthritis deformans (chronic non-tuber- 
culous arthritis), which shows how closely chronic gout may resemble 
arthritis deformans. 

A woman, white, married, 77 years old, occupation, housework, 
was seen at the Boston Almshouse and Hospital, at Long Island, 
suffering from rheumatic pain in her knees for three years, although, 
at times, she had had slight attacks of pain for twenty years past; 
she was well developed, somewhat stout, heart slightly enlarged on the 
right with a systolic murmur at the apex, radial artery sclerotic, 
no tremors, left knee stiff, unable to close the fingers tight or to 
completely extend them, motion at the wrist also slightly limited 
without deformity, pain, or tenderness, motion in right elbow slightly 
limited, shoulder motion considerably limited but without pain, tender- 
ness or deformity. 

There was no particular change in the patient's condition during 
her eight months stay, but she gradually became weaker and she 
died in coma. 

At the post-mortem examination, the right knee showed a joint 
apparently normal, except that the articular cartilage on the con- 



296 ORTHOPEDIC SURGERY. 

dyles of the femur showed considerable shallow pitting and over some 
parts which were not pitted there was an irregular deposit of chalky, 
white material which could be removed, leaving surfaces resembling 
the eroded areas above described. Similar deposits were seen on 
the patella and to a very slight extent on the tibia. 

Microscopic examination of the deposit showed it to consist of 
urate crystals. 

Chronic gout is little understood as it is so uncommon. Clinic- 
ally it is characterized by painful and stiff joints; it makes slow 
progress with periods of acute exacerbations coming irregularly 
when new joints may be affected, or it may be confined to those pre- 
viously involved. 

Chronic gout seems different from acute gout; it may begin as acute 
gout or may follow irregular or masked gout. Gouty concretions are 
different from Heberden's nodes because they are attached to the soft 
parts and not to the bone; sinuses may form after a while leading 
to these tophi, and osteomyelitis may follow and destroy most of a 
phalanx of finger or toe slowly as the process involves little of the 
bone at a time, gradually extending into the shaft. Either the shaft 
or the ends of the phalanx may be affected first; if the latter, then 
the corresponding end of the adjacent bone is involved and the joint 
is destroyed as in the atrophic type of arthritis, but with this difference 
— in gout there is destructive disintegration of bone and union like a 
fracture and there is no atrophy of the soft parts, whereas, in atro- 
phic arthritis, the atrophy of both the bone and soft parts is the 
prominent symptom, and the phalanges appear in X-ray to be 
crowded or telescoped together without losing the articular outlines. 

Disintegrated bone is thrown off in small crumbs through sinuses 
from which at first pure urate of soda from the chalk-stone was 
discharged. During an attack, or while deposits of urates are being 
made about the joint, the elimination of urea by the kidneys is de- 
creased; at other times, there may be a great excess of uric acid 
elimination. 

Patients with chronic gout are dyspeptic and have sallow com- 
plexions; they may have arteriosclerosis with hypertrophy of the 
left ventricle. 



DISEASES FROM DISORDERED NUTRITION. 297 

Treatment. — But little is known about treating them. Rest 
in bed during an attack, and local warmth to the affected part 
relieves pain; sweating with rubber tissue or flannel is helpful; 
dyspepsia should be treated during the acute stage by a liquid or 
soft solid diet, and after the attack, if the digestion will stand it, 
forced feeding is desirable. Throughout the disease, especially 
during the acute stage, large quantities of water should be taken 
and the amount of urine should be kept large. There is no reason 
why meat and nitrogenous food should be excluded. 

Colchicum or the salicylates may be used to cut short an attack ; 
iodide of potassium and the benzoates have been recommended; 
quinine and iron as a tonic afterward; hydrotherapeutic measures, 
blistering, or superficial brushing with the Paquelin cautery, hot- 
air baking, and massage have also been tried. 

FUNCTIONAL OR HYSTERICAL JOINT DISEASE. 

Functional or hysterical affections of the joints may be divided 
into two groups — those which are simulated, and those in which the 
symptoms are exaggerated, — the symptoms of a disease or injury 
which has been or is still present. 

SIMULATED DISTORTIONS. 

The first class of cases, of course, includes the malingerer, who is 
rare but not unknown in childhood. 

Joint Disease. — Attempts to simulate the limp of hip disease are 
usually easy to detect. There are many symptoms of hip disease 
besides the limp, limitation of motion due to reflex muscular spasm 
may be simulated but the simulation will be detected when the 
patient's attention is withdrawn from it; muscular atrophy is absent, 
hence distortion without atrophy or shortening should arouse sus- 
picion. If the process has been one of long duration we expect, 
in hip disease, to find evidence of deep infiltration or commencing 
abscess which is not found in the hysterical, nor is shortening. 

In the knee, simulated disease can be excluded often in the same 



290 ORTHOPEDIC SURGERY. 

manner. Hysterical club-foot can easily be differentiated from the 
congenital variety but may simulate paralytic club-foot; by the 
history, anterior poliomyelitis, and spastic paralysis can usually be 
excluded, and the other nervous diseases which produce paralysis 
have definite symptoms. If doubt remains, the electrical reactions 
of the muscles are tested. Atrophy in hysterical club-foot is very 
slight or wanting. Cases of hysterical scoliosis have been reported. 
Whitman mentions one with an exaggerated lateral twist of the spine 
so that the shoulder approached the pelvis, the spine was flexible 
and straightened completely in recumbency, and complete recovery 
followed the settlement of a suit for damages. 

Neuromimesis. — In the second class of functional affections of 
the joints, a physical basis for the symptoms is always discoverable; 
they are a neuromimesis. Trauma is frequently an exciting cause 
and the pain seems to persist indefinitely without ascertainable 
cause except for the patient's abnormal sensitiveness and self-con- 
centration. They are therefore called habit pains. Slight phys- 
ical abnormalities which would give no inconvenience to a normal 
person produce exaggerated symptoms. Careful examination usu- 
ally shows the presence of neurasthenia. At other times, organic 
and functional diseases are present together; a joint affection, which 
on examination appears to be of a mild character and in the con- 
valescent stage, is considered by the patient to be most acute and 
the true character of the joint can only be detected by careful and 
most gentle examination with the patient's attention distracted. 
While the symptoms of neuromimetic disease are subjective only, 
certain objective signs of structural trouble may be present, such 
as atrophy from disuse, distortions which are usually unlike those 
seen in disease ; increased warmth over the limb may be observed and 
local sweating, but other physical signs of disease in the affected 
joints are generally absent. 

In the spine, a sensitive, painful condition is often present as the 
result of a slight accident. This may persist for many months, is 
characterized by sensitiveness over the spinous processes of the verte- 
brae, pain on motion and manipulation. It is generally associated with 
neurasthenia. The pain and tenderness are often localized at the 



DISEASES FROM DISORDERED NUTRITION. 



299 



base of the neck, between the shoulders, low dorsal region, the end 
of the spine; they are aggravated by fatigue, and are accompanied by 
hyperesthesia, or by burning sensations. 

Patients may refuse to sit or stand because they cannot bear 
weight on the spine. Sometimes the back is held stiffly, except 
when the patient's attention 
is diverted. In most cases, 
the normal attitude in stand- 
ing is really somewhat at fault; 
a short leg, a round, or hollow 
round back, or extreme lordo- 
sis is present, and the muscu- 
lar development is very poor; 
backache of this type results 
sometimes from flat-foot or 
contracted foot; sprains of the 
vertebral column may cause 
considerable disability and 
persist for a long time; stiff- 
ness and pain may cause a 
mistaken diagnosis of Pott's 
disease and may also lead 
to a train of symptoms such 
as we have just described. 

Treatment. — It is import- 
ant from the outset that the 
surgeon be sure of his diag- 
nosis. A definite plan of treat- 
ment must be adhered to; at 
first the patient's general con- 
dition must be brought as nearly normal as possible; then the patient 
is to be trained to regain the use of the disabled limb or spine. Rest 
in recumbency part of the day must be secured in all cases in which 
the spine or hip is involved; careful and continuous routine exercises, 
careful feeding, and such medication as is necessary for the general 
health must be insisted upon. 




Fig. 149. — Hysterical scoliosis. (Lovett.) 



300 ORTHOPEDIC SURGERY. 

The amount of attention to the local condition must be varied 
for different patients. An important part is the improvement of the 
circulation and strengthening of the surrounding muscles. Massage, 
local hot-air baths, electricity, gymnastic exercises, even the vibrator 
may be of great service. Exercise must be in graded amounts 
slowly increased, each advance is an important gain. The mechan- 
ical active and passive exercises when available are of great use — 
the appliances of Zander and others are most valuable. As a rule, 
mechanical apparatus like braces and splints are to be avoided but 
in some cases with marked muscular weakness they are temporarily 
useful, as in a patient with a very weak back who was much bene- 
fited by wearing a light steel brace with flexible tempered uprights. 
Crutches likewise are of temporary utility. For functional affections 
of the ankle, knee, and hip, it is sometimes advisable to remove the 
effect of weight-bearing by a high sole on the sound foot and the use 
of crutches. 

In both groups of cases even if no physical cause for the disa- 
bility can be found to exist, it is a mistake to belittle the symptoms 
or treatment. The patient's co-operation must be secured and a 
gradual gain, even if slight, should bring encouragement. These 
cases vary in difficulty and often tax the physician's ingenuity severely, 
but he should remember that his success depends largely upon his 
own judgment, and failure may leave his patient a hopeless invalid. 



PART IV. 

DEFORMITIES FROM PARALYSIS AND FROM AFFEC- 
TIONS OF THE MUSCLES. 



CHAPTER XVIII. 



DEFORMITIES FROM DISEASE OF THE NERVOUS AND 
MUSCULAR SYSTEMS. 

INFANTILE PARALYSIS. 

Infantile paralysis; anterior poliomyelitis; acute atrophic spinal 
paralysis; infantile spinal palsy; infantile spinal paralysis; essential 
paralysis of childhood; paralysie spinale; paralysie infantile; tephro- 
myelite; Kinderlahmung; poliomielite ; mielite anteriora. It is a 
common disease and produces about 
7 percent of all deformities. 

The affection was first described 
in 1840, as an affection of children; 
though essentially a disease of child- 
hood, Taylor, in the Out-patient 
Department of the Massachusetts 
General Hospital, found seventy-six 
adult cases during a period of 4J 
years. It may begin in infancy as 
early as the twelfth day after birth; 
it comes both in epidemics and 
sporadically, Most cases appear 
between May and September. An 
epidemic was correctly observed in 
1843 but for 45 years after that 
time its epidemic nature was for- 
gotten. 

Fully two-thirds of the cases at the Children's Hospital, in Boston, 
fall between the ages of 6 months and 4 years, or in the period of 
the first dentition. It frequently comes on in a night, it attacks 
boys and girls, healthy and unhealthy alike. The acute onset 
and its occurrence in epidemics in summer, have led to a belief that 

3o3 




Fig. 150. — Old infantile paral- 
ysis: back-knee and varus, walk- 
ing with a crutch. 



k 



304 ORTHOPEDIC SURGERY. 

it is infectious. The infecting organism has not been demon- 
strated. The Weichselbaum-Jager diplococcus of spotted fever 
was found in cerebrospinal fluid withdrawn by lumbar puncture 
on the thirteenth day of the disease by Schultze; but as paralysis 
attending cerebrospinal meningitis is sometimes indistinguishable 
from infantile paralysis, this evidence is not conclusive. 

Epidemics have been reported by Caverly, in Rutland, Vt., Alston, 
in Australia, Madison Taylor, in Cherryfield, Me., J. J. Putnam, in 
Boston, and E. G. Brackett, in North Adams, and recent epidemics 
have occurred in Italy, in California, in Alabama and elsewhere. 

The following cases, reported by Brackett, occurred during the 
summer of 1894 at North Adams, Mass. Out of several times that 
number affected 10 children were seen and examined and data were 
obtained both from the parents and the attending physicians; they 
had all been ill between the middle of August and the 18th of Sep- 
tember, except a single case on the 25th of July; the invasion was 
sudden and sharp. Fever, headache, vomiting, delirium, or stupor, 
preceded by a distinct interval the advent of paralysis; in one case 
they were said to have preceded it 21 days; the initial fever was 
over 106 in 3 cases, stupor and delirium were present often; 8 out 
of the 10 cases lost control of the sphincters, 5 of the bladder only, 3 
both of rectum and bladder, 2 of the 8 had incontinence 5 years 
afterward; of the 3 in whom the rectum was affected, 1 did not 
regain control for 15 months, another for 2 years; hyperesthesia 
was found to be so marked in 5 cases, that the weight of the bed- 
clothes could not be borne; 1 had anaesthesia, a rare condition; there 
was loss of speech in 2 ; and one was blind for two weeks. The severe 
nature of the attacks is readily seen from this account. 

Pasteur, in 1896, reported an epidemic occurring in 7 members of 
the same family. 

Severity is the characteristic of epidemics. Sporadic cases 
are milder, as both the symptoms and the extent of the paralysis 
are less. 

Pathology. — The pathology of the early stages is not known. 
Later the gray matter and the ganglion cells of the anterior horn 
are involved in an interstitial inflammation and there is a resulting 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 305 

degeneration of the motor or ganglion cells of the anterior cornu. 
It is believed the inflammation works its way in along the peri-vas- 
cular spaces around the small blood vessels in the anterior commis- 
sure of the cord. In a few autopsies the spinal meninges were in- 
flamed. The paralysis is always flaccid and it is seldom that there are 
sensory disturbances, like hyperesthesia, or paresthesia. The anterior 
nerve roots may dwindle considerably in size. The paralyzed 
muscles are relaxed, flaccid, and much atrophied, the limb cool or 
cold and the foot more or less cyanotic. It is said that one can 
predict from its color whether there is a chance for a muscle to recover, 
for complete cutting off of nerve supply produces in time a fatty 
change in the muscular tissue so that the color becomes a pale, 
opaque, yellowish-white; shades from pink to red indicate a muscle 
less completely cut off and with greater chance of recovery. This 
color change is used by Hoffa as an aid in operating. 

Symptoms. — The stage of onset is seldom seen by the orthopedic 
surgeon, and is often mistaken for other diseases by the physician. 
It may be preceded by fever, and restlessness for several days with 
vomiting, and in infants by convulsions or by pain in a limb; but 
paralysis may, however, come suddenly without premonitory symp- 
toms and this has been called the subacute variety of poliomyelitis. 
The severest cases at the onset may be unconscious with frequent 
vomiting, with retention of urine or incontinence of both urine and 
feces; and vomiting may be of the cerebral type. There often 
is pain in the limb before paralysis is discovered. Paralysis comes 
suddenly and is often paraplegic in type, although all sorts of distri- 
butions may be found; monoplegia, and paraplegia comprise three- 
quarters of the cases; diplegia, crossed paralysis and paralysis of 
the muscles of the back and abdomen are found; but hemiplegia 
is unusual and the respiratory muscles and those of the face are 
never involved. 

With the advent of paralysis the prodromal symptoms subside. 
The paralysis attains its height in a few hours, and the stage of con- 
valescence begins with an improvement so gradual that it is at first 
unnoticed. The paralysis, even at its height, affects whole groups 
of muscles like the extensors, adductors, and supinators. Under 



3°6 



ORTHOPEDIC SURGERY. 



improvement, certain groups show a return of strength while others 
do not. After six or eight months, the improvement usually comes 
to a standstill, but some unrecovered muscles still slowly gain, perhaps 
for two or three years. The unantagonized muscles pull, distort 
and produce both deformity and disability. When the calf muscles 
are paralyzed, the patient walks on his heel; when the anterior 
tibial group of muscles are affected, on his toes; and if the peroneal 
muscles are then stronger, a valgus position is added; if the peroneal 
muscles only are paralyzed, the position is varus. 

Children may have complete flaccidity of the leg below the knee 
or of the entire limb, and the same is true less often of the 

/ 





Fig. 151. — Paralytic valgus. 



Fig. 152. — Paralytic 
valgus. 



upper extremity. Muscular atrophy is rapid and extreme, and 
begins early. The bones fall behind in their normal growth, shorten- 
ing always occurs, for one limb often recovers its function and grows 
while the other grows less fast. The paralyzed limb is cold, 
flabby, relaxed, and lifeless. The skin is blue from passive hyper- 
emia and poor circulation. A third stage, the period of deformity, 
is not sharply defined and is marked by static paralysis and con- 
traction distortions. It is for this that the orthopedist usually is 
consulted. 

The deformities are due to lack of growth, or shortening, and to 
the effect of paralysis. Shortening of an arm is comparatively un- 
important, but in the leg, if uncorrected, it miy induce lateral cur- 
vature by tilting the pelvis. 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 307 

Deformities due to paralysis are manifold. They seldom appear 
sooner than two months after the onset and usually not for many 
months. They have been divided into those caused by the con- 
traction of unopposed muscles, and those due to laxity of the 
muscles and ligaments. Weak muscles always stretched by a 
stronger antagonist muscle or by the body-weight in walking 
can not regain strength. For this reason it is, even early 
in the disease essential to support and to retain the limb in 
normal positions, e.g., the foot at a right angle to the leg, etc. 

The thigh muscles which are most affected are the internal and 
the anterior groups. The glutei and hamstrings are only involved 
in complete paralysis of the leg, jambe de Polichinelle. The loss 
of the anterior group seriously interferes with locomotion and when 
the child finally learns to walk, the forward step is made through 
the action of the sartorius and psoas muscles flinging the knee out- 
ward and upward more than forward; furthermore, there is ina- 
bility to stiffen the knee and the erect position of the limb is main- 
tained only by pressing on the front of the thigh with the hand to 
prevent the knee from doubling up when the weight is on it. When 
the entire limb is paralyzed, the psoas, unopposed, produces flexion, 
adduction, and rotation outward of the hip, while the knee and 
foot hang limp. Nature attempting to make the limbs parallel, 
drags and tilts the pelvis, rotates it on a transverse axis, and in 
time produces lateral curvature of the spine. 

At the knee, contraction in the flexed position is common and 
is often accompanied by subluxation and by knock-knee; but if 
on the other hand, laxity predominates, the knee hyperextends and 
abnormal lateral mobility arises. Hyperextension of the knee- 
joint when combined with paralysis of the extensors, which lock the 
knee in walking, may be a good thing, as it enables the patient to 
walk without pressing his knee back with his hand, for the mechanics 
are now reversed and under loading the hyperextended knee, tries 
to hyperextend more instead of flexing, hyperextension being limited 
by the posterior ligament. Outward rotation of the tibia upon the 
temur is also a common occurrence. 

Below the knee the anterior tibial muscles and peronei are fre- 



308 ORTHOPEDIC SURGERY. 

quently involved together, resulting in a toe-drop and later in talipes 
equino-varus, or if the peronei be intact, equino-valgus. With a 
backward knee an equinus position of the foot is necessary 
that the toes and heel may touch the ground together. Pure flat-foot, 
calcaneo-valgus, and calcaneus are much favored by lax ligaments. 
In the two former, severe grades of flat-foot may develop from 
walking, and in talipes calcaneus the unsupported front of the foot 
drops, causing extreme hollow foot, pes cavus, not unlike the form 
of the foot of the Chinese lady which has been distorted by bandag- 
ing. 

The Paralytic Sequelae. — Deformities which may be reckoned 
as sequels of this paralysis are lateral curvature of the spine, and 
paralytic dislocations. 

Lateral curvature of the spine results in three ways: From 
pelvic obliquity due to legs of unequal length; from unilateral paral- 
ysis of the muscles of the back; and from other faulty attitudes due 
to paralysis, e.g., paralysis of one arm, or of one serratus magnus, 
or one sterno-mastoid. The effect of paralysis of different muscle 
groups is given by Schulthess; paralysis of both sides of the back 
leads to carrying the head and the upper part of the trunk leaning 
backward so that the weight may antagonize the muscles of the 
front; with loss of abdominal muscles, on the contrary, one bends over, 
or leans forward for similar reasons; paralysis of shoulder muscles 
is mechanically not unlike ankylosis of the shoulder, in that the 
thorax tries to support and fix it; paralysis of one leg throws the body- 
weight over the sound hip by inclining the spine to that side and 
backward; just how it does this depends on the distribution or 
involvement of the muscles of the hip and pelvis. Paralytic curva- 
tures are always of long radius, bad postural curvatures may 
arise from paralysis of the back muscles and also curves which are 
symmetrical and may be very disfiguring. 

Schulthess and Hoffa have seen exceptional cases in which the 
curve in partial paralysis of the back muscles was convex toward 
the most paralyzed side, but as a rule the curve is convex toward the 
stronger side, and is especially pronounced in the sitting position. 
Partial paralysis of the abdominal muscles gives, as a rule, a curva- 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 30Q 

ture convex to the weaker side, often a kypho-scoliotic curve, but the 
direction of the curve may be to either side. Paralysis of an arm 
may produce a curve in the spine, (if the deltoid and biceps are para- 
lyzed,) which is high and convex to the side of the paralyzed arm. 
A similar condition is seen in obstetrical paralysis. In scoliosis 
from infantile paralysis of the lower limb, the shortening and the 
peculiar distribution of the paralysis makes it difficult or im- 
possible to determine the mechanism by which the curve becomes 
a right or a left one. 

Paralytic dislocations are uncommon accompaniments of the severe 
cases. The hip may dislocate spontaneously in bed or in walking; 
and usually the head lies on the dorsum ilii. If un- 
reduced, the dislocated head may become firmly at- 
tached and the leg be fairly useful but short. A 
dislocation may be reduced after many months and 
reduction has occurred spontaneously. The knee-joint 
may be so lax that a partial dislocation takes place at 
each step. Subluxation of the knee is not uncommon 
from the unopposed pull of the hamstrings. Paraly- 
sis of the deltoid muscle may produce dislocation of the 
shoulder. 

The electrical reactions of paralyzed muscles are „ FlG " ? 53 "7~ 

1 - Paralytic 

usually typical by the second or third week. equinus' 

The faradic irritability of muscles which are com- 
pletely paralyzed may be completely lost by the second week, 
although in later years a trace of irritability to faradism may be 
found. Muscles without any faradic irritability early in the disease 
are almost always destined to remain paralyzed. In testing with the 
galvanic current, all the affected muscles respond slowly, and respond 
only to stronger currents than they would normally. Normally, the 
cathodal closing contraction should be stronger than the anodal, but 
in infantile paralysis, closure of the positive pole gives the greates 
contraction. This is the "reaction of degeneration." It requirer 
only a little experience to use this electrical test and to interpret it 
correctly. Babies and little children are so constantly active that 
the test is not reliable on them. 




3IO ORTHOPEDIC SURGERY. 

TREATMENT OF INFANTILE PARALYSIS. 
Treatment. — As the diagnosis is seldom made before paralysis 
appears, the treatment is often not what one could have wished 
in the early stage. Free catharsis, lying on the side or stomach, 
blisters and cups over the spine, the administration of ergot, the 
bromides, and strychnia, have been recommended. The general 
condition of the child should be kept as good as possible, and the 
fever lessened by baths. 

During the stage of convalescence some of the paralysis gets 

well rapidly, and one should aim to 
maintain a normal position of the limb, 
to guard against overstretching the 
joints, ligaments, and muscles. The 
nutrition of the paralyzed muscles 
should be encouraged by daily fara- 
dism, massage, and exercises. 

The feet should be kept at right 
angles to the leg and the weight of the 
bedclothes be removed. As the circu- 
lation is feeble, straps and bandages 
are to be avoided as much as possible. 

P^lectricity may be begun as early as 
Fig. 154.— Paralytic calcaneo- the end f the first week; a gentle gal . 
valgus. 

vanic current through the affected mus- 
cles and nerves at first, later, those muscles which contract feebly to 
faradism should be stimulated, and those which do not respond to 
faradism can be exercised by the interrupted galvanic current. Dry 
warmth and rubbing are very important, and anything which stimu- 
lates the circulation, like dry heat, helps nourish the muscle. Skilled 
massage is probably better than the mother's rubbing, but the latter 
should not be discouraged, for rubbing is a good part of the treat- 
ment. Active exercise is also essential but the muscles must not be 
tired. Exercises should be graded carefully for each child and at 
first moving the limb with the hand should aim to assist the weak 
muscles to use any power they may have, and there should be exer- 
cises whenever the rubbing or massage is given. 




DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 311 



Mechanical Treatment. — This treatment aims (i) to restore loco- 
motion, (2) to antagonize distortions and maintain correct position 
by supporting the joints in normal positions, and by preventing dis- 
placements to make walking possible; it may also overcome 
deformities already present. Obviously, no special form of appa- 
ratus can suit the individual peculiarity of each case; all sorts of 
modifications of apparatus are to be used, one should not be limited 
to a few appliances, but rather use his ingenuity in devising what- 
ever is best for each individual patient. It is always better in the 
stage of deformity to have the patient walk on his foot, — not use an 
apparatus which allows walking with the foot kept off the ground. 

To control simple talipes calcaneus, 
a single side upright extending to a 
hand's breadth below the knee may be 
attached to the sole of the boot with 
an ankle-joint stop to prevent dorsal 
flexion but allow free plantar motion; 
and it is better to insert a plate be- 
tween the leathers of the sole to pre- 
vent its bending. 

For equinus the apparatus figured in 
Chapter XXI, page 383, may be used 
with either single or double upright 
and the same may be modified for cal- 
caneus. See Chapter XXI, page 383. 

The equino-varus position which is more common may be supported 
by the apparatus for club-foot (Chapter XXI, page 383), and for valgus 
the apparatus shown in Chapter XXI, page 382. If needed these sup- 
ports for the ankle and sole may be incorporated into a longer splint to 
control the knee or hip. Pes cavus may be treated by inserting a 
thin steel between the leathers of the sole of the boot with an extra 
strap buckling the instep down on to it. Fasciotomy of the plantar 
fascia is often desirable. 

When the muscles of the thigh are strong it is not necessary 
to prolong the upright above the knee. Appliances should be 
as light as possible on account of weakness of the leg. When 




Fig. 155. — Paralytic calcaneo- 
valgus. (Children's Hospital.) 



312 ORTHOPEDIC SURGERY. 

the quadriceps is paralized, the knee doubles forward when 
weight is borne upon it, and to make locomotion possible it is 
only necessary to prevent the knee from bending forward. A sim- 
ple way to prevent this is shown in Chapter XXI, page 375. 

Leather lacings may be added to the apparatus, which by cover- 
ing a large area of skin, substitute surface for localized pressure. 
Should the knee hyperextend, a broad leather strap passing behind 
the knee will correct this. More complicated splints, hinged at 
the knee for convenience in sitting may be seen in Chapter XXI, 
page 381. 

When paralysis is extensive a limited degree of locomotion is 
given by attaching the upright above the hip to a leather jacket; a 
caliper knee splint may be used, jointing the outside upright at the 
trochanters. 

The muscles of the back are seldom paralyzed without paralysis 
of the leg, and complete paralysis of the back is disabling. Partial 
paralysis may be helped by the use of a leather jacket, a spinal 
brace, or corset, which connects with leg splints to make standing and 
walking possible. 

It is difficult to control paralysis of the abdominal muscles which 
produces great lordosis in standing. A waist band or corset may 
be tried. 

Appliances to Correct Distortions. — Mechanical treatment may 
be used to correct flexions and distortions of the joints, although 
these are better remedied by surgical means. 

Flexion of the hips is hard to correct by mechanical means because 
it is so hard to fix the pelvis. Two caliper splints (Chapter XXI, page 
375) are attached to a leather jacket by side irons hinged over the tro- 
chanters. Bending forward is then limited by straps from the 
knees which are buckled to the back of the jacket while the child 
walks about on crutches. Flexion of the knee may be straightened 
by bandaging the leg to a splint (Chapter XXI, page 373) in the fol- 
lowing manner: the bandage is applied under one upright over the 
thigh, under the other upright and over the thigh, and so on, 
until the knee is covered where it is firmly fixed. If there is a ten- 
dencv to subluxation the head of the tibia should be forced forward 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 313 

by a leather strap between the uprights immediately behind it. 
Walking is then encouraged. If the deformity is severe, however, 
the patient should be confined to bed and traction by weight and 
pulleys should be made as seen in Figure 134, page 257. 

A leather knee-cap on a caliper splint may slowly straighten 
flexion of the knee, or a turn buckle may be applied as recom- 
mended by Eliot to a hinged knee splint or the Shaffer's splint, or 
it may be corrected by weekly applications of plaster bandage with 
the knee extended each time as much as possible. 

The mechanical correction of deformities of the foot is tedious 
and operative measures are to be preferred. Corrective plaster-of- 
Paris bandages applied under anaesthesia are of benefit. The walk- 
ing appliances used for the various forms of talipes are modi- 
fied to suit the requirements of each individual. 

Operative Treatment.— Three different objects are to be attained 
by operative measures for infantile paralysis deformities: (1) the cor- 
rection of deformities; (2), muscle transference, or the application 
of the power left in the leg in a more serviceable direction, and 
(3), nerve grafting to cause a return of nerve power to some of the 
paralysed muscles. 

The deformity from infantile paralysis which one has to correct is 
usually a flexed hip, a flexed or subluxated knee, usually combined 
with knock-knee and paralytic talipes. Most of these conditions 
may be overcome by forcible manipulative correction under ether, 
with tenotomies, fasciotomies, and fixation in plaster bandages. 

Subluxation of the knee may be reduced by the method of Whit- 
man or by ordinary manipulation. The genuclast is seldom neces- 
sary. See chapter XVI, p. 258. 

Resistant flexion of the hip usually requires an open incision to 
divide the contracted fascia lata which is not involved alone, but 
there are intra-muscular partitions which need division too. Os- 
teotomies for knock -knee or even excision of the knee may be 
necessary in rare cases. 

These measures do not restore mechanical force, they only 
assist the mechanics of locomotion. Arthrodesis of the ankle-joint 
and resection of the knee are also done to obtain stiff joints in a 



314 ORTHOPEDIC SURGERY. 

useful position to walk on in cases of complete paralysis with 
flail joints. 

The writer knows of one patient, a woman in middle life, who 
as a young girl of sixteen had the left ankle and knee-joint resected. 
She is well, has a useful limb, though slightly lame. 

Arthrodesis of the Ankle. — Arthrodesis of the ankle-joint is often 
done for flail-ankle to obviate the irksomeness of wearing apparatus 
for life. Of several different methods, that of Kocher offers the best 
view of the joint. Under full anaesthesia, a semi-circular incision 
is made around the external malleolus, the tendons of the peroneus 
longus and the peroneus brevis are found and divided between two 
silk guide stitches; the external ligaments of the ankle are divided 
and the foot supinated inward while any remaining attachments 
of the capsule anteriorly and posteriorly are cut to allow complete dis- 
location inward. With chisel and knife every vestige of articular 
cartilage is pared away from all the surfaces of the joint, tibia, 
malleoli, trochlear surface and sides of astragalus. The joint is 
then replaced, the external lateral ligaments sutured, the peroneal 
tendons united by their silk guides and the wound sutured, dressed 
and encased in a plaster-of-Paris bandage, taking care that a 
serviceable position of the foot is maintained in plaster. After- 
treatment demands three months with the foot in plaster, and dur- 
ing this time crutches should be used and the foot swing free of the 
ground. This should be followed by walking on a stiff-ankled sup- 
portive apparatus (see Chapter XXI, page 376); daily massage, and the 
use of the support should be continued six months. 

Dane found the results following this operation at the Children's 
Hospital, in Boston, far more serviceable than those following tendon 
transference. Townsend, at the Hospital for Ruptured and Cripples, 
in New York, concludes that the relapses after arthrodesis for para- 
lytic club-foot properly performed are less frequent than after tendon 
transplantation. Bony anklyosis is not essential [in young chlidren 
and is not often obtained. Hertz, of Aukland, New Zealand, nails 
the astragulus to the external malleolus and the calcaneus to the 
astragalus by silver staples after doing arthrodesis to secure firmer 
union. The staples are left in situ. 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 315 

Tendon Transference. — Tendon anastomosis or suture had been 
done in wounds severing the forearm tendons since 1780, when Nic- 
oladoni, a hundred years later, used it to ameliorate paralysis. It 
was only some thirteen years later that the value of this operation 
began to be known. 

Tendon transferences may be done in several ways; either a strong 
muscle may be made to pull a paralyzed tendon or it may be shifted 
to a new bony attachment; in the first case a sound muscle may 
be divided and the tendon of a paralysed one attached to it, 
or a paralysed muscle may be divided and the tendon attached 
to a sound muscle nearby, or a sound tendon may be split and 
part transferred to a paralyzed tendon; in the other case the whole 
or a part of the tendon of a sound, strong muscle may be trans- 
planted into a new attachment made into or beneath the perios- 
teum. This second method, devised in 1900 by Lange,of Munich, 
transfers the attachment of a strong tendon to a new locality, 
and is of great use in the foot as it is possible almost always to find 
some new point of attachment which will be effective; the chief draw- 
back is the insufficient length of many tendons, a difficulty which 
may be remedied by piecing out the tendon with several strands of 
stout silk. 

As Lange points out, much depends upon the amount of strength 
remaining in the transferred muscle. In his operation, besides 
the strength remaining in the muscle, much depends upon fixing it 
in such a new place that it pulls to greatest advantage; in other 
words, it should be attached at a point where it gives on contraction 
the required motion. Langc also showed that when the tendon is not 
long enough strands of braided silk quilted into the end of the ten- 
don and attached into or beneath the periosteum may be employed, 
and he has shown that fibrous tissue forms about the strands and 
between the fibres of the silk, converting it practically into new 
tendon. The silk should be boiled in 1-5000 corrosive sublimate 
solution. 

It is better to make the limb bloodless before operating. The incis- 
ions, the points of insertion, and the tendons employed must vary 
according to circumstances. 



316 ORTHOPEDIC SURGERY. 

Iii transplanting tendons into the periosteum a more solid attach- 
ment may be secured by dividing the periosteum with a chisel, 
lifting a small bony flap on each side, stitching the tendon into the 
gap, and the periosteal flaps over it. Mutter does still more. He 
bores through the bone, passes his tendon through the hole, loops 
it back on itself and stitches it tight. 

Tendon Shortening. — Hoffa, in addition, does much for the correc- 
tion of paralysis by shortening or lengthening the tendons of muscles 
which are paralyzed or paretic. In order to determine whether they 
are paretic or completely paralyzed, he makes an exploratory incision 
over the belly of the muscle to see its color; pink and pale reddish 
muscles are paretic, yellow and white ones are hopelessly degenerated. 
He shortens the tendon by taking a tuck in the following manner: 

He lifts the tendon on a director approximating the points of inser- 
tion and origin as much as possible and quilts a strong silk suture 
above and below into the tendon he thinks two points can be ap- 
proximated; the ends are tied together and then tied around the loop 
of tendon which is held up on the director. Then this loop can 
either be cut away or stitched to the tendon above or below. 

Tendon lengthening can be done either by a simple tenotomy; 
by the operation of splitting the tendon in two lengthwise, dividing 
each half at a different level and stitching them together; or the Z- 
shaped tenotomy may be done according to the method of Bayer, 
which means dividing a little more than the right half of the tendon 
at one point, and the left-hand half considerably higher up, and 
forcibly stretching until the fibres slip by each other. In order to 
obtain more width after splitting the tendon, Vulpius splits it 
parallel to the skin instead of at right angles to it. 

Many different forms of quilting sutures have been used in sutur- 
ing tendon to tendon. They have met with some success but the final 
results of simple tendon anastomosis are generally unsatisfactory 
in children, for either they come apart, or the piece of paralyzed 
tendon stretches, or the old tendon forms anew and takes the strain 
off the work. 

David Silver, of Pittsburg, in an experimental study of the effects 
of sutures in the tendons of animals, finds that the suture maintains 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 317 

apposition of two tendons during repair without exerting sufficient 
tension to produce necrosis, in fact that it is hard to tie a suture tight 
enough to cause tendon necrosis. Union begins in about five weeks, 
for the stitches suffer constant strain, partly from normal muscle tone 
and partly from involuntary contractions, because the tension at the 
time of operation has to be high. Tendons have a meagre blood 
supply and many relapses are due to tearing out of a suture. The 
high degree of quilting or interweaving of suture and tendon, advo- 
cated by Lange, does not appear to cause necrosis. 

A tendon's blood supply is from two sources: from the belly and 
bone insertion of the tendon, and from the sheath ; for this reason the 
sheath should be replaced about a tendon after operation. 

Hoffa found the process of repair still in progress 242 days after 
operation, which shows that owing to poor blood supply, tendons 
unite very slowly, true repair beginning only four or five weeks after 
operation and continuing for 8 or 9 months. Silver believes that failure 
through insufficient hold of the suture in the tendon is common, 
but from overtight suture it is very rare; that the process of repair 
is slower in a transplanted than in one sutured after a wound, prob- 
ably because the circulation of the reinforced tendon is disturbed 
by separating it from its surrounding tissues; and owing to defects 
in the synovial sheath. 

Silver's experimental work throws a more favorable light upon 
Nicoladoni's method of suturing two tendons, but emphasizes the 
importance of restraint and fixation for many months after operation. 
To accomplish this without joint stiffness gentle massage and exercise 
are to be employed daily. 

Before operating, the surgeon should map out exactly what he means 
to do. There are different ways of making that paralyzed limb useful, 
and a combination of methods, muscle transference, muscle lengthen- 
ing, and muscle shortening should all be considered. It is essential 
to know whether muscles are paralyzed or paretic, for paretic 
muscles stretched for months by strong antagonizing ones seem 
unable to contract. Electric stimulation should be tried, and if 
that fails an exploratory incision over the belly of the muscle to see 
its color. 



318 ORTHOPEDIC SURGERY. 

Schantz holds that there are a few definite points on the foot 
for the proper application of muscular force from the leg. That 
for a simple equinus, an insertion should be made on the front of 
the foot, on both sides; for an equino-varus, on the outside of the foot; 
and for valgus on the inner side, and he tries by long incisions 
to get the tendon in a straight line from its origin to insertion. He 
believes the power-giving muscle should never be severed from its 
old attachment, a slip may be taken from it to establish a new 
one. For suture he uses an aluminum-bronze wire which later 
he found covered with tendinous tissue; the superficial wound 
should be closed tightly. 

A list of the principal transplantations combined with muscle 
shortening and lengthening for different paralytic deformities of the 
foot follows: 

For paralytic equinus. Lengthening of the tendo Achillis with 
shortening of all the anterior tibial group of muscles. 

For paralytic equino-varus. A slip for re-enforcing is prepared 
from the outer border of the tendo Achillis which is then lengthened; 
the anterior tibial group of muscles are shortened, the peroneus 
longus and brevis are shortened and the slip from the tendo Achillis 
brought over and transplanted into them. 

For paralytic valgus. Shortening of the tibialis anticus tendon 
and transplantation of the extensor longus hallucis tendon into the 
scaphoid near the anticus insertion, with lengthening of the peroneals ; 
or Lange's transference of the peroneus longus tendon to an 
attachment on the inner side of the calcis. 

For paralytic calcaneus. Shortening of the tendo Achillis (Wil- 
let's operation) with transference of the peroneal tendons and part of 
the extensor crommunis digitorum into the insertion of the tendo 
Achillis. 

Lange uses artificial silk tendons attached to the periostum 
directly; for instance, in order to secure a straight position of 
the foot in paralytic equino-varus, where the tibialis anticus is the 
only strong muscle, he splits its tendon and attaches the outer half 
to the periosteum of the base of the fifth metatarsal bone. 

To restore extension to the knee from paralysis of the quadriceps 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 319 

muscle the sartorius is transplanted into a slit in the quadriceps 
tendon at the upper border of the patella, or either the biceps or the 
ilio-tibial band preferably the biceps, may be transplanted into 
the same attachment; but Lange instead brings forward the 
biceps and semitendinosus tendons which are too short to be planted 
into the patella, so he lengthens the tendons with four stout silk 
strands and sews the ends of these strands into the side of the 
patella and also into the periosteum of the tibial tubercle. Gluck, 
in 1892, and Kiimmel, in 1896, had pieced out tendons with silk. 
Believing that necrosis of a tendon is very rare, he stretches the 
tendon as tight as possible in suturing. 

Tendon Transference in the Arm. — Tendon transplantations have 
been of benefit in paralysis of the upper extremity. Tubby trans- 
planted long strips from the outer head of the triceps into the biceps 
tendon, close to its insertion in the radius to restore flexion at the 
elbow. Efforts to restore the deltoid by transplanting the whole 
of the clavicular portion of the pectoralis major and part of the 
trapezius into the deltoid's insertion, have been made both by 
Tubby in England and Soutter in this country. The angel wing 
deformity from paralysis of the serratus magnus has been cured 
by transplanting the lower part of the pectoralis major into the 
serratus magnus. Wrist-drop has been improved by Robert Jones 
and others by transplanting active carpal flexors into paralyzed 
extensors and this operation is done for spastic paralysis also. 
Tubby converted the pronator radii teres into a supinator by detach- 
ing its tendon insertion from the radius, passing it through the 
interosseous membrane and refixing it on the outer side of the su- 
pinated radius, an operation which has been successfully repeated 
by Bradford and others. When the muscle was too short, Tubby 
grafted the central end of the pronator radii teres into the 
flexor carpi radial is, bringing that tendon through the interosseous 
membrane after dividing it, and fixing it to the outer border of 
the radius. 

Townsend reported seventeen cases of tendon transplantation 
in the forearm, and says that paralytic wrist-drop after cerebro- 
spinal meningitis can be cured, if a new muscle plan be properly 



320 ORTHOPEDIC SURGERY. 

worked out, as extensor muscles may be transplanted into paralyzed 
tendons and vice versa. The after-training is very important, and 
requires many months of careful work. As in the leg, tendon 
graftings are useless in flail joints from complete paralysis. 

Tenodesis. — Hoffa found that he could fix a flail-like ankle by 
shortening all the muscles on both sides of the joint in the manner 
described on p. 316. This method, called by Reiner tenodesis, is avail- 
able also to prevent toe-drop where there is little power left on the 
extensor side and as an accessory in tendon transferences. Through 
a vertical incision at the junction of the middle and lower thirds of 
the leg the tendon of the tibialis anticus is found and shortened in 
the usual manner; then a stout silk is sewed into the periosteum of 
the tibia or fastened through a small hole drilled in the bone and tied 
to the suture which makes the tuck in the tendon; the same is done 
to the other tendons fastening them to the fibula. The term tenodesis 
is used to mean fixation of a joint by shortened tendons, as arthrodesis 
means fixation by bony union. 

Shortening of ligaments may be done to compensate for the over- 
stretching from misapplied weight. It has been little used and usu- 
ally silk strands have been tied through holes drilled in the bones, 
which are apt to fret out or wear through in a year; shortening by 
quilting stitches may be tried, for even a temporary gain is worth 
while. 

NERVE GRAFTING. 

Nerve anastomosis and transplantation have been attracting more 
and more the attention of surgeons for the past few years, but 
although a number of successful and partly successful results have 
been reported, the operation is not yet in common use. 

In 1897, Sick and Sanger tiansplanted the distal stump of a para- 
lyzed musculo-spiral nerve into the neighboring intact median nerve, 
and obtained a good result. Faure and Furet, in the following 
year, sutured part of the spinal accessory nerve into the divided 
facial nerve, which was paralyzed, without improvement. 

Harvey Cushing, five years later, transplanted the proximal stem 
of the divided spinal accessory into the distal end of the paralyzed 



DEFORMITIES FROM THE NERVOUS AND MUSCULAR SYSTEMS. 32 I 

facial with success, and numerous experiments of nerve transference 
were made on dogs, showing that control and coordination, as well 
as power, were restored. 

Spitzy, from experimental studies on animals, believes that the 
best method is to split oft a part of an intact nerve, to implant 
it into a longitudinal slit in the. paralyzed nerve and fix it there; 
he calls this a central transplantation; or else he cuts off a paralyzed 
nerve and plants the peripheral end into a longitudinal slit in the in- 
tact nerve, a peripheral transplantation. 

If he suspects that some of the paralyzed nerve may still be 
active, the central end too may be put into the intact nerve higher 
up. The first method, central implantation, is to be used, if an 
intact nerve is at hand whose muscles are not important to loco- 
motion; the peripheral method if only large nerves of equal import- 
ance to locomotion can be grafted together. 

Peckham, of Providence, in 1900, restored power to the extensor 
muscles of the foot by transplanting two branches from the internal 
popliteal nerve into the external popliteal. Both patients had paral- 
ysis of the peroneal muscles. In one improvement began two or 
three months after operation and was much greater after a year. 

The second case, an adult with infantile paralysis from childhood, 
had a fairly good return of power in the peronei three months after 
operation. 

Young, of Philadelphia, operated, in 1902, for paralysis of the 
tibialis anticus muscle and the child had considerable return of power 
eighteen months later. Dr. R. T. Taylor, of Baltimore, had improve- 
ment in three cases. Tubby, in two cases of talipes calcaneus, and 
two of paralytic equino-varus, reported favorable results in two of 
the four. Excellent results have followed the application of this 
method to the treatment of facial paralysis. Unfortunately, one 
does not often find motor nerves, which can be utilized, lying close to 
paralyzed ones. A portion of the spinal accessory has been used 
to vitalize the paralyzed facial with success; the hypoglossal has been 
planted into the facial with success; portions of the external popliteal 
into the internal popliteal and vice versa; the musculo-cutaneous 
nerve into the peroneal or the muscular branches of the peroneal 



32 2 ORTHOPEDIC SURGERY. 

into the musculo-cutaneous nerve in the leg; in the elbow, the radial 
and median nerves may be grafted and in the brachial plexus, the 
nerve trunks and cords. Nerve graftings have only been attempted 
in a few localities. 

Sherren collected twenty-five examples of nerve sutures and 
graftings, in twelve of which sufficient time had elapsed for recovery 
of motion to take place; of these only two were failures, some im- 
provement taking place in all of the others. 

Nerve grafting and sutures in the brachial plexus for obstetrical 
paralysis have been noted in Chapter VI, page 80. 

Thorburn reports a case of secondary suture of the whole brachial 
plexus seven months after an injury, resulting in partial return of 
strength. Sherren did suture of the upper and middle trunks of 
the plexus, nine weeks after division; no improvement in sensation 
was noticed one hundred and eighty-two weeks after, but full volun- 
tary power had returned in the biceps. Not until three hundred 
and thirty-three weeks after did the paralyzed muscles react to fara- 
dism. 

Spitzy, from dissections on the cadaver, finds that a branch from 
the obturator nerve which supplies the pectineus and gracilis is 
easy to find and may be passed through a canal made under the 
fascia, and grafted into the anterior crural nerve, near Poupart's 
ligament. This might restore the innervation of the quadriceps. 



CHAPTER XIX. 
DEFORMITIES FROM DISEASE OF MUSCLE. 

TORTICOLLIS. 

Torticollis, or wry-neck is neither common nor rare. It appears 
in the clinic about once to ten club-feet and one-fifth of these wry- 
necks are congenital. It is confusing only because the deformity 
may be produced by such different causes, and so it is spoken of 
as congenital or acquired, true or symptomatic, reflex, and spas- 
modic, all terms which are rather vague. 

Congenital torticollis has a short sterno-mastoid muscle which is 
usually the result of fetal myositis; although the association of other 
malformations suggested another explanation for the condition, mi- 
croscopic study of sections of the muscle removed at operation by 
Kirmisson showed a transformation into fibrous tissue of the pos- 
terior part of the muscle, a scarring from inflammation which adhered 
to the muscle sheath. One sterno-mastoid is affected, very rarely 
both. From this shortening malposition of the head arises, the face 
turns toward the unshortened side and the chin tips that way, too, 
so that a prolonged median axis of the head would pass through the 
breast on that side, while the ear is low on the side that is shortened. 
The face, in fact the whole half head, is small on the side of the con- 
traction, the skull shows it and there may be structural scoliotic de- 
formity of the cervical spine and sometimes a double curve. 

Spasmodic torticollis is something quite different, the usual posi- 
tion of the head is that of wry-neck, but it is continually jerked 
aside by spasmodic contractions which are uncontrollable. Its cause 
is unknown, perhaps some minute irritating lesion of the cortex of 
the brain as yet undiscovered; it follows some infectious diseases like 
typhoid fever and I have seen it in a case of chronic lead poisoning. 

Controlling the movements of the head in an apparatus has been 

323 



3 2 4 



ORTHOPEDIC SURGERY. 



of benefit and is reported to have cured. A patient of Dr. Hall, 
of Marblehead, could stop the jerky movements by pressing on the 
back of the neck with his hand, and a light steel spring clasping 
the posterior two-thirds of the neck, sufficed to control it. Others 
are most rebellious to treatment. Excision of the spinal accessory 
nerve which supplies the trapezius has given relief occasionally; 
other nerves have also been excised without benefit. 

Roswell Park had a patient with aggravated spasmodic torticol- 
lis, an adult, in whom the jerky movements were entirely cured 




Fig. 156. — Congenital 
torticollis, left sterno- 
mastoid contracted. {Chil- 
dren's Hospital.) 




Fig. 157. — Congenital torticol- 
lis. Features of left side of face 
small. (Children's Hospital.) 



after the excision of two inches from the sterno-mastoid and the 
removal of a large triangular section from the cervical portion of 
the trapezius and the much thickened omo-hyoid. Many bands 
of connective tissue were cut or stretched — in fact, the operation 
consisted in open division of everything in the neck which resisted 
stretching from immediately above the clavicle to the occiput. 

The other forms do not have jerky movements. 

Symptomatic torticollis means that the deformity has arisen as 
a symptom of caries of the spine with the spasm in the posterior 



DEFORMITIES FROM DISEASE OF MUSCLE. 325 

neck muscles, or of cervical adenitis. Traction in bed is to be 
used in cervical caries to diminish the deformity- 
False or transitory torticollis is a transient form formerly con- 
sidered rheumatic; they are frequently due to a slight adenitis or 
even sore throat and subside under a few days in bed. 

Dermatogenous wry-neck arises from the contraction of large 
scars and is to be cured by plastic operations transplanting skin 
flaps. 

Acquired torticollis includes those which come without known 
cause and those due to faulty use of the eyes or ears as in deafness 
in one ear. 

Diagnosis is easy when one is on the watch for this deformity, 
but sometimes the children's parents cannot be made to notice it; 
facial asymmetry is less easy to detect — the line of the nose is not ex- 
actly at right angles to a line connecting the pupils of the eyes, the 
corners of eyes and mouth are closer together on the cheek which 
is less prominent, and all the features are a little smaller on that side. 
The skull is altered; one side of the alveolar arch may be a 
little smaller both in the upper and lower jaw, and the whole skull 
shows a twisted growth of the bones of the face, as if nature were 
trying to make the crooked features straight. This is plainly seen 
in several skulls in the Warren Museum. See Chapter VII, page 85. 

Treatment is directed to lengthening the shortened muscle which 
is usually the sterno-mastoid muscle. It may be stretched or cut; 
and slow stretching by apparatus has been used, but the writer has 
had no experience with it. 

Stretching. — Slow manual stretching by the mother three or four 
times a day has been successful in some babies. Rapid complete 
stretching under full anesthesia is done by Lorenz, of Vienna, and 
by Wilson, of Philadelphia. The overcorrected position is main- 
tained for many months, at first in plaster, later in an apparatus. 

This method has the advantage of leaving no scar; after-treatment 
should include exercises and massage for six months. 

The operator grasps the etherized patient's head with both hands, 
turning the chin with force till it points to the shoulder of the affected 
side, which renders the muscle very tense, and under massage it 



326 ORTHOPEDIC SURGERY. 

is felt to yield. If the contracted muscle cannot be elongated suffi- 
ciently, still more forcible massage is used, kneading and hacking 
at the muscle close to its clavicular end until resistance to passive 
motion is overcome, then it is fixed in a plaster helmet jacket ap- 
plied in extreme overcorrection with the face, ears, and the top of 
the head left uncovered. 

Open division of the Sterno-mastoid. — The usual incision is one 
parallel with the clavicle, a finger's breadth above it over the sternal 
and clavicular heads of the short muscle. As a preliminary, the posi- 
tion of the external and the anterior jugular veins should be verified 
by compressing them under the finger at the center of the clavicle 
and over the sternal notch. 

Dividing the skin, the superficial and part of the deep cervical 
fascia, the sternal head is exposed, freed from its sheath, a director 
passed beneath it, and it is cut across with a knife; the upper end 
snaps back, but often only a half inch or less because its strong 
fibrous sheath, still undivided behind, adheres to the deep layer of 
cervical fascia attached to the sternum. Division of this sheath and 
fascia has to be done with great care for it is in immediate contact 
with the internal jugular vein, which is much widened at this point. 
After completely dividing this fascia one turns the head to see if 
division of the clavicular attachment is also necessary. It may be 
left if the head can be overcorrected easily, but it usually requires 
division in the same manner and with the same precautions as the 
sternal head. 

An aseptic operation and a clean view of the field is essential; 
one should stop each bleeding point immediately so as to recognize 
each structure as it presents. The skin and the superficial fascia 
may be sewed with a subcutaneous catgut suture, and the wound 
dressed with a small sterile dressing fastened with flexible collodion. 
To avoid a depressed scar, and at the same time to seal off the deep 
wound, it is a good plan to have the skin drawn firmly upward before 
incising, so that when the suture is applied, the wound lies at the 
lower border of the clavicle, whose shadow partially conceals it. 

Lange's Operation. — Lange, of Munich, divides the insertion of 
the sterno-mastoid into the skull at the mastoid process and the outer 



DEFORMITIES FROM DISEASE OF MUSCLE. 327 

part of the superior curved line of the occipital bone because the 
wound is smaller and is concealed by the hair. In rare instances 
other muscles, like the scalenus anticus and the splenius capitis, 
need dividing, but they can at times be stretched. Thorough 
stretching should always be given after division and before applying 
a plaster bandage. Real shortening of the trapezius is rare; and 
contraction or spasm of the muscles of the back of the neck is a 
signal to look out for cervical caries, although it may also arise from 
adenitis secondary to pediculosis capitis. After operation the head 
should be secured immediately in a plaster-of-Paris bandage in over- 
corrected position. This bandage should include the chest above the 
ensiform cartilage, the neck, chin, occiput, temples, and forehead. 

Still under ether, the little patient sits on a low stool, with the 
head supported by two loops of flannel passing under the chin and 
occiput firmly held by the hand of an assistant. The entire area 
to be covered by plaster is protected by cotton batting with thin felt 
over the prominent bony parts. The plaster bandages are immersed 
and quickly applied to the chest, shoulders and neck, taking care 
when the head piece is added to get correction, that is, the greatest 
possible separation behind the divided ends of the muscle. In trim- 
ming the plaster, it is essential to leave sufficient space in front of 
the chin and over the eyes, to leave the ears uncovered, and allow 
plenty of room about the axillae and shoulders. It should not be 
uncomfortable, as it is to be worn six or eight weeks, followed by 
apparatus which is light and less unsightly for going to school and 
has the advantage of being removable. For description of appar- 
atus see Chapter XXI, page 356; the brace, also exercises for the neck 
and shoulders should be used daily and the brace should be worn 
at all times of the day except when exercising; at night it is un- 
necessary. 

MYOSITIS OSSIFICANS. 

Anomalous sessamoid bones are often found in normal tendons. 
Other bone formations in muscles have been described as myositis 
ossificans. They are of two types: the first, characterized by the 
ossification in succession of various muscles all over the body, is of 



328 ORTHOPEDIC SURGERY. 

unknown cause and is called myositis ossificans progressiva; the 
second type is a local condition due to long continued irritation, 
to excessive use, or to injury — the so-called rider's, fencer's and 
dancer's bones belong in this category. This bone formation is 
limited to the muscle in which it is situated. The traumatic type 
comprises those due to injury and they are generally associated with 
traumatic bone tumors, osteomata growing from bone. 

Theories have been advanced but the method of formation is 
unknown. They are not formed out of effused blood nor are they 
aberrant sesamoid bones. They may be due to the growth of in- 
cluded fetal tissue; some pathologists consider them the results of 
inflammatory changes in intermuscular connective tissue, and Grawitz 
and Salmon on clinical and microscopical grounds believe the bone 
arises from cloudy degeneration of muscle fibres, with a small celled 
infiltration of the connective tissue. 

In some instances no inflammatory changes are found. Robert 
Jones believes that it may then be caused by the detachment of small 
bits of periosteum; as similar growths have been produced in rab- 
bits by Berthier who detached small portions of periosteum and 
the muscle insertions and stimulated the muscle with electricity. 

The bone patches consist of soft cancellous bone with large mar- 
row spaces filled with blood corpuscles and some giant cells. 

In life traumatic myositis ossificans may be suspected after dislo- 
cation of a joint like the elbow if, in spite of good treatment and ap- 
parent cure, a gradually diminishing range of motion develops. The 
presence of hard tissue near the joint makes the diagnosis clear; but 
Robert Jones emphasizes the fact that these symptoms are exactly 
those which convince a surgeon that he has mistaken an obscure 
fracture for a simple dislocation, and is at last recognizing it by its 
large callus. 

Out of a total of 339 cases of the traumatic type, the great bulk 
of them were found in young men fom twenty to twenty-five years. 

Sometimes they adhere to the bone, sometimes they are freenn 
the muscle; they are more common in the lower limbs than in the 
upper; only a small proportion are found in women. 

Treatment consists in removing the bony deposits if they give 



DEFORMITIES FROM DISEASE OF MUSCLE. 329 

any trouble. The X-ray should guide us both in diagnosis and at 
operation. Complete removal of the bone should be aimed at, for 
if any is left it will grow. When attached to bone, it is neces- 
sary to chisel well into the shaft to avoid regrowth. No more 
definite rules of operation can be laid down, as it may grow anywhere. 
After the operation, absolute rest is enjoined for two or three weeks, 
and early passive motions are avoided. 



CHAPTER XX. 
PLASTER-OF-PARIS. 

It is important for the orthopedic surgeon to fit and adjust his own 
apparatus and in exceptional cases to make it himself; especially 
those whose patients are in the country and in towns where of in- 
strument makers there are none. 

General practitioners may often do much for orthopedic patients 
by means of the plaster bandage and plaster casts They should 
be familiar with the technique of plaster work. One of the essentials 
to success lies in using the proper materials for making the plaster 
bandage. 

Bandage Cloth. — Starch stiffened crinoline gauze is the best mate- 
rial and it may be procured in many varieties; a gauze running 30 
threads to an inch is the best for plaster bandages. Crinoline gauze 
is sized often with dextrin or glue which retards the setting time of the 
bandage or prevents it. To determine between the dextrin and starch 
sizing the iodine test may be found convenient; or a piece of gauze 
may be chewed for the taste of dextrin may be recognized easily. A 
small amount of dextrin, a one percent solution, prolongs the time 
of setting, with larger amounts, the plaster fails to set. Starch 
contained in the bandage has no effect on the setting time of the 
plaster, and tends, perhaps, to increase its tensile strength. A good 
starch sized crinoline at present on the market is the "Vigilant" 
which comes by the piece, 30 inches wide and 24 yards long. 

Plaster. — Plaster-of-Paris is chemically a native sulphate of lime, 
called, in the crude state, gypsum. It is prepared for use by pul- 
verizing finely and calcining in ovens at a temperature between 
300 and 350 F. which drives off its water of crystallization. Prop- 
erly burned plaster when mixed with water recrystallizes or sets 
into a solid mass. A plaster bandage practically sets without expan- 

33o 



PLASTER-OF-PARIS. 33 1 

sion or shrinkage because the plaster tends slightly to expand and the 
cloth to shrink. It really expands a trifle in setting (one percent). 
Two sorts of plaster are in use in orthopedic work, a quick set- 
ting fine plaster, known as dental plaster, and commercial plaster 
which is coarser and sets more slowly. Either may be used for 
casts but only the fine dental plaster for bandages. During the 
setting latent heat is set free, it becomes warm; this indicates that 
the chemical process has begun and is a signal not to disturb the ban- 
dage for fear of interfering with its set. The addition of salt, alum, 
or sulphate of potash to the water accelerates the time of setting but 
lessens its strength and durability; one-twentieth part by volume of 
Portland cement makes the setting quicker and increases the dura- 
bility and strength. 

Preparation of the Bandage. — There is no better way of prepar- 
ing plaster bandages than by hand. Strips of crinoline 4 yards long 
and of the required width (2 J-4 inches), are loosely rolled and placed 
upon a smooth surface and with semicircular motion dry plaster is 
rubbed into the meshes. After 12 or 15 inches of crinoline have been 
rubbed full of dry plaster it is rolled up and the adjoining portion of 
the gauze has plaster rubbed in; this is repeated until the entire ban- 
dage has been rubbed full of dry plaster. Plaster bandages should 
be kept in a dry place, preferably in wooden boxes. 

R. O. Meisenbach, of Buffalo, to whom I am indebted for many 
valuable suggestions, has added greatly to the strength and dura- 
bility of his bandages by mixing with his plasters one-twentieth part 
by bulk of Portland cement. Owing to increased resistance to both 
crushing and tearing, these bandages are applied thinner than or- 
dinary plaster bandages. 

The Application of the Bandage. — The part of the body to receive 
the bandage is first protected by a layer of stockinette or by strips 
of sheet cotton batting bandaged on. Protection may be very thin 
if one expects no swelling to occur; but when swelling is expected 
or when the bony prominences are very marked, this protective padding 
must be very thick to guard against pressure sores — for instance, for 
a plaster jacket it is not necessary to wind the body in sheet wadding; 
an undershirt or stockinette with felt pads over bony prominences 



332 ORTHOPEDIC SURGERY. 

suffices; but if the bandage is applied after a forcible correction of 
club-foot, the cotton padding must be very thick and soft. 

Having selected the proper bandages for use they should be laid 
horizontally in a pail full of water about 70 F., not stood upon end 
lest the plaster powder settle to one end of the bandage. When the 
bubbles cease to rise it is taken out, grasped at each end with the 
hands, and squeezed so that no plaster can escape. To insure a 
homogeneous set of the entire dressing, Meisenbach has each bandage 
wrung a little dryer than the preceding, In applying, the bandages 
should be unrolled a foot or more, wound about the part with 
even pressure, and each layer should be thoroughly rubbed with the 
hand as it is applied. Speed in application is important that the 
whole dressing may be finished before setting takes place. After 
the last bandage is applied no more plaster paste or water should 
be added. Smoothness may be attained by rubbing for a few 
seconds with a towel. The number of bandages depends on the 
nature of the part and the age of the patient; roughly speaking eight 
or ten layers are sufficient excepting over the hip and knee. The 
plaster bandage turned upon itself may be used to reinforce weak 
places, or a strip of wood or metal may be incorporated between 
the layers of plaster. After setting has once begun the limb must 
be held motionless until the process is completed, a period of about 
seven minutes. Rubber gloves may be used to protect the hands. 
The edges of the plaster are trimmed with a knife and finished by 
turning down over the outside of the bandage a half-inch of the 
material used to protect the skin. 

Width of Bandages. — For the legs and for plaster jackets the 
bandages should be from 3 to 4 inches wide and 4 yards long, and 
should weigh 6 or 7 ounces with the plaster rubbed in. For babies 
with club-feet 2 inch bandages should be used and the length should 
not exceed 3 yards. In order to facilitate soaking up water, the 
bandage should be rolled on a lead pencil or a round stick which is 
withdrawn leaving a hole in the middle; all bandages are to be 
rolled loosely to facilitate quick penetration of water. 

If it is impossible to obtain crinoline gauze stiffened with starch, 
the dextrin sized gauze may be soaked and washed so as to remove 



PLASTER JACKETS FOR POTT'S DISEASE. 333 

the sizing; but this washed material wrinkles, is more difficult to 
cut and tear and receives the powdered plaster less readily. 

Removal of the Plaster Bandage. — When it is desirable to in- 
spect the position of a limb encased in plaster within a few days of its 
application it is advisable to bivalve the plaster soon after setting, 
that is to cut through the plaster with a knife on either side of the leg 
so as to divide it into two pieces; a wet gauze bandage is then applied 
tightly around the plaster which by its shrinkage holds the two pieces 
firmly together. To remove a plaster which has not been bivalved, 
the plaster should be moistened where the cut is to be made by means 
of a medicine dropper or coarse camel's-hair brush with either water 
or weak acetic acid, and the wet place is cut through with a sharp 
knife. Many saws, knives, and shears have been devised to cut 
plaster. A short-bladed knife set in a stout round wooden handle 
is convenient. Care must be used not to cut the patient's skin. 

After applying a plaster jacket, if it is tight and there may be little 
room for respiration, it should be cut down the front immediately and 
bandaged together with a cloth bandage so that it may be sprung 
open in case of emergency. Windows may be cut where sinuses are to 
be dressed or in order to remove pressure from given points. Lorenz 
always leaves next to the skin a strip of soft gauze protruding at each 
end of the completed bandage which the patient can use as a scratcher, 
to remove crumbs, etc. Pain, offensive smell, or a spot of discharge 
on the plaster indicates a pressure sore and calls for immediate re- 
moval. Generally, plaster bandages may be worn many months. 
At the Children's Hospital, in recent years, jackets for caries of the 
spine have been worn undisturbed for a year or more; this was 
done because during the process of changing the jacket the spine 
is necessarily disturbed and the deformity may be increased in 
the handling. 

PLASTER JACKETS FOR POTT'S DISEASE. 

Plaster jackets are employed in the treatment of Pott's disease, 

lateral curvature, round shoulders, and after operations for wry-neck. 

Plaster jackets for caries of the spine have been applied in many 



334 



ORTHOPEDIC SURGERY. 



ways and the one described here, known as the hammock frame 
method, has been long in use at the Children's Hospital. The 
jacket is applied with the child lying on his face on a strip of cloth 
stretched on a frame as the recumbent position relaxes the muscles 
of the trunk and enables the operator to see exactly how much 
lordosis is present. The hammock frame, a quadrilateral made of one 
inch galvanized iron pipe joined by elbows is 6 feet long by 2 feet 
wide, so supported that the upper end is about 4 feet high, and the 
lower 3J feet. Two S hooks at the high end hold an iron rod which 
is passed through the hem of the hammock while at the lower end of 
the frame a 15-inch screw with a handle is connected by an iron 
spreader with a similar bar in the other end of the hammock. 
The hammock itself is made of cotton sheeting twice as wide as 




Fig. 158.— Original hammock and frame for jackets; the one 
described is better in many ways. 



the distance between the iliac spines and a little longer than the 
child is tall; it is doubled lengthwise and a wide hem made in 
each end. The hammock is attached to the frame, tightened, and 
the child is placed upon it face downward, with his upstretched hands 
grasping the top of frame. Around the side bars of the frame, and 
passing under the hammock, is a tight webbing strap to give support 
under the sternal notch and a similar tight strap crosses the frame 
just above the knees. If the hip is flexed by psoas contraction the 
child may be made to straddle the hammock, the knees are partly 
bent. The child should wear an undershirt or stockinette covering 



PLASTER JACKETS FOR POTT'S DISEASE. 



335 



and the padding should be adjusted to protect the sacrum, the crests 
of the ilia, the sternum, clavicles, and axillae. Felt an eighth of an 
inch thick answers for this purpose. At the point of deformity 
pads of felt, an inch or more thick, are placed extending over the 
transverse processes opposite the point of deformity and for an 
inch or two above and below as well. No 
padding is allowed over the spinous pro- 
cesses. The bandages are then applied 
up to and including the point of de- 
formity; each layer is rubbed in and the 
jacket allowed to set, during which time 
the child lies quiet. Then by loosening 
the screw the hammock is allowed to sag 
under the child's weight. The lumbar 
spine, being held by the plaster jacket, 
is thereby prevented from further bend- 
ing, so that the sagging produces a back- 
ward bending at the point of deformity 
against counterpressure from the straps 
under the sternal notch and beneath the 
thighs; the deformity can often be cor- 
rected considerably by the pressure of the 
surgeon's hand over the upper portion of 
the jacket; more plaster bandages are 
then applied to complete the jacket, and 
it is again allowed to harden. It is easy | 
to apply a jacket like a figure of eight, 
leaving the upper portion of the abdomen 
exposed if desired. If it is necessary to 
carry the jacket over the shoulders, to in- 
corporate in it a plaster collar or helmet, 
the upper portion of the jacket is made high in the back, otherwise 
it should cover the lower angle of the scapulae above, and end below 
at the center of the sacrum; in front it should cover the sternal 
notch and more than half of the clavicles, and it should be cut out 
under the arm pits freely. 




Fig. 159.— Plaster jacket 
applied on a hammock 
frame, notice the trans- 
verse ridge where the two 
sections of jacket join. 



33^ 



ORTHOPEDIC SURGERY. 




To remove the child from the frame, he is supported while the 
hammock cloth is cut above and below. It is better to have him 
stay after completing the jacket on the frame about ten minutes 
or until the plaster is well hardened, but if it be necessary to re- 
move him before the plaster is entirely set, he 
should be laid on a table with his back arched 
up with pillows between the head and hips. If 
one wants to add shoulder pieces, a collar or a 
helmet, the hammock is no longer a convenient 
place. The child should lie on a table with the 
head and shoulders projecting beyond the edge, 
supported by an assistant; after padding the parts 
with cotton, plaster bandages are applied, care- 
fully rubbed and incorporated into the already 
well-hardened jacket. 

PLASTER BED. 

Fig. 160.— Plas- It is often desirable in Pott's disease to make 

te.r Jacket with uge f h laster bed pl aste r shell for recum- 
windows cut. L ' * 

bency to keep the back well arched, either for the 

prevention of deformity or for the paralysis. 

The hammock made slack is an excellent place to make it on; with 

the screw the amount of hyperextension which can be comfortably 

borne is easily regulated. The patient lies face down and the plaster 

bandages are applied after protecting the skin and hair with cloth 

or thin pads; the bandage turns pass upward and downward from the 

top of the head to half way between the gluteal fold and the bend of 

the knee. Five layers of these long forward and back turns are 

applied from the top of the head to the bottom of the plaster, 3 

radiating from the point of deformity as a center, and two extra layers 

are applied to the sides of the bed in straight longitudinal turns, then 

cross turns cover in the whole shell; if necessary for strength, pieces 

of wire gauze may be incorporated or thick strips of cotton batting 

soaked in plaster cream may be added to the outside to strengthen 

it. When well hardened it is lifted off, and the patient's back is 

washed, dried, and he is dressed, and returned to bed. The pro- 



PLASTER JACKETS FOR POTT'S DISEASE. 337 

visional padding is then removed and the walls of the plaster 
bed carefully smoothed, the shell trimmed, cut away from the 
arm pits and the whole thoroughly dried and shellacked. Fresh 
padding is then suitably fitted to the bed and stork linen to cover 
the lining over the buttocks and the patient is carefully rolled onto 
his side and then into his plaster bed to which he is attached by cir- 
cular turns of bandage. By cutting away the part which covers the 
top of the head, traction may be added, either in bed by weight and 
pulley or by the jury mast incorporated in the plaster bed if he is 
to move about in a go-cart. See page 222, Fig. 115. 

OTHER METHODS OF APPLYING PLASTER JACKETS. 

Different surgeons and different hospitals have different methods 
of applying plaster jackets and what each uses most he uses best. 
The recumbent position has always commended itself to the writer 
because it conduces to the comfort and quietness of the child and 
allows a fair amount of correction of deformity by the weight of the 
child's body. A frame similar to the hammock frame, with the 
patient lying on his back, is used by Goldthwait for applying the 
plaster jackets. 

Goldthwait Method. — In the center of the frame, a hanging cross- 
bar carries a short upright with a forked end adapted to receive the 
upper ends of two soft flat iron bars which sustain the spine like 
the two uprights of a brace; they are bent for each case and 
give the proper amount of hyperextension to the back. The lower 
end of these bars is supported on a cross-bar running from side to 
side at the level of the hips, where they are clamped by a simple turn 
button into slots. The head and feet are supported on adjustable 
pillow and crosss straps. Thick felt padding is put on the soft 
iron flat bars and the child prepared for his jacket, wearing an 
undershirt, is laid upon them, so that the top of the bars or uprights 
comes a little above the kyphos and the head and feet are supported 
on the straps (the head is supported on a small pillow on two straps 
across the frame) ; by loosening the straps excellent correction is ob- 
tained. The legs and feet rest on a board. 

The jacket is applied in the usual manner with the iron uprights 



33* 



ORTHOPEDIC SURGERY. 



inside of it. The bandage is reinforced in front by half turns up and 
down; after setting, the turn button is unclasped, freeing the bottoms 
of the upright iron bars, and allowing the patient to be lifted from 
the frame and laid on his side on the table or bed, when the uprights 
are easily slipped out. The jacket is trimmed in the usual way. 

In BrackeWs frame the patient is on the back, only instead of 
lying on long iron bars he is supported at the kyphos on two short 
metal plates well padded with felt which are raised or lowered on 
a Y-shaped support to give the proper amount of correction to the 
deformity; the plates are left inside the jacket. 




Fig. 161. — Brackett's frame for applying a plaster jacket. 



Lovett Frame jor Jackets. — In Lovett's frame for applying plaster 
jackets, the patient lies on his face on two broad webbing straps 
with a cross strap at the trochanters and one at the level of the 
forehead; the upper half of the frame is made double and hinged 
and the straps secured to it; with legs hanging down to ensure a 
straight lumbar spine, the first half of the jacket is put on up to the 
point of deformity and allowed to harden; then a webbing strap is 
tied across over the child's back at the point of deformity thickly 
padded, and the hinged front half of the frame is raised by an as- 
sistant, thereby raising the upper part of the trunk against pressure 
from the strap over the kyphos. This force has to be graded to 



PLASTER-OF-PARIS JACKETS FOR LATERAL CURVATURE. 339 

suit the patient's feelings. The upper half of the jacket is then ap- 
plied, and thoroughly incorporated with the lower part. 

The Kyphotome. — Taylor, of Baltimore, uses an appliance called a 
kyphotome attached to an ordinary office stool, bearing on the top a 
bicycle saddle; back of the patient there is fixed to the stool an iron 
upright six feet high bearing a cross bar from which handles and 
a Sayre head sling are suspended; this stout upright rod is jointed 
and bears a circle with holes in it so that the extension may be applied 
directly above the patient's head, or it may be tipped backward so 
that he is pulled back considerably; just below the joint is an adjust- 
able rod or lever for making pressure upon the kyphos during the 
application of the jacket; the feet and thighs are secured to the side 
of the stool by straps. 

The patient, in his undershirt, is placed on the saddle, his legs and 
hips are strapped in, the part of the spine below the deformity is 
made perpendicular to the floor by means of the pressure rod which 
is placed a little above the apex of the kyphos; then the head sling is 
put on and as much traction made as the patient can bear, the hands 
being extended upward and backward on the handle rods; the up- 
right above the pressure rod is then tipped back to any angle desired 
and fastened, strongly extending the spine. The reason for placing 
the pressure rod and its pads above the kyphos is that the child rises 
under extension slightly; the jacket is then applied. 

This method is applicable to lumbar, low dorsal, and mid-dorsal 
cases which require plaster collar. Anaesthesia is not needed. 

Taylor also uses a recumbent kyphotome attached to a table, 
which he can use both for lateral curvature and for Pott's disease. 

The original method of Sayre of applying the jacket in partial 
suspension is an excellent one and is much used. 

PLASTER-OF-PARIS JACKETS FOR LATERAL CUR- 
VATURE. 

The jackets are applied for lateral curvature either for support, 
or for the forcible correction of deformity. 

The plaster jacket for support may be applied on the hammock 



34° ORTHOPEDIC SURGERY. 

frame or by other methods. Some correction of the lateral devia- 
tion is obtained by a padded webbing strap passed around the 
chest opposite the point of greatest deformity and around the side 
bar on the opposite side of the frame, while counterpressure is 
made by two similar straps, one around the pelvis and the other 
at the axilla; by tightening these straps and arranging the padding 
some straightening may be had even in stiff structural cases. Rota- 
tion of the ribs may be corrected by pressure with the hands, by hang- 
ing weights upon these straps, or by screw pressure from adjustable 
bars on the frame. The jacket is then applied in the usual manner 
all in one piece; after hardening, the webbing straps are cut close 
to the jacket and covered with an extra layer of plaster bandage. 

More forcible correction may be obtained with Taylor's kypho- 
tome or modification of the hammock frame of Adams and Lovett. 
This consists in three circles of iron, almost as wide as the frame, 
which are adjustable toward the head and foot and also can be 
turned; each bears an adjustable plunging rod to press on the chest 
or back through a metal disc thickly padded with felt. The lateral 
deviations are corrected by straps, the rotations of the ribs by the 
pressure of the discs; the jacket is put on in the usual way, leaving 
the diVcs inside; it is easy to apply more corrective pressure than 
a patient can tolerate, and is therefore better to apply two or three 
jackets a month apart than to try to accomplish too much at once. 

REMOVABLE JACKETS. 

Plaster jackets may be made removable by cutting an inch out 
of the front of the jacket and sewing on each side of the cut a strip 
of leather with eyelets or hooks for lacings. The top and bottom 
of the jacket may be bound with sheepskin. 

Leather Jackets. — The strength and efficiency of a plaster jacket 
is materially impaired by converting it into a removable appliance, 
and jackets of other materials may be substituted, such as stiff- 
ened felt, leather, celluloid, aluminum, and paper -and-glue. These 
are made on a plaster cast of the trunk made by pouring plaster 
cream into an old jacket. Leather is simply stretched while wet 
over the cast and secured by tacking until it is thoroughly dried. 



REMOVABLE JACKETS. 



341 



It is then removed, trimmed, and leather strips with eyelets or hooks 
for lacings sewed at the anterior margins, and it is then thoroughly 
impregnated with boiling bay's wax to stiffen it. The jacket is 
perforated every two inches with half-inch holes to lessen per- 
spiration. The advantage of the bay's wax jacket lies in our ability 
to remodel it over any points where it hurts. By simply heating the 
place where the change is desired, the wax is melted, and the leather 
softens so that it can be moulded and held in the desired form 
with a stick until, in cooling, it re- 
sumes its former hardness. The plaster 
casts for jackets may be altered in shape 
by carving or by building on more 
plaster paste, so that the jacket will 
fit a corrected position of the trunk. 
Jackets are valuable aids in the treat- 
ment both of scoliosis and caries. 

Celluloid jackets are prepared by 
covering the cast with a merino under- 
shirt or stockinette, and painting on 
two or three layers of a saturated solu- 
tion of celluloid in acetone. More 
stockinette or a layer of bandage is ap- 
plied as soon as dry, then another coat 
of celluloid and so on until the desired thickness is reached. These 
celluloid jackets dry very slowly and if removed before drying is com- 
plete, they shrink and curl out of shape. They should be perforated, 
for celluloid provokes perspiration. Another method by which cellu- 
loid jackets are made is the following: a large sheet of the cellu- 
loid, softened in boiling water, is stretched on the cast with tongs. 
The operator, with thick, woolen gloves, quickly rubs it to insure close 
adaptation, and the jacket is ready for trimming as soon as it is 
cool. The disadvantage of celluloid jackets lies in the fact that they 
are hot: their chief advantage is that they are washable and cleanly. 

Corsets made of cloth re-inforced with steels and other materials 
have been used extensively but the support is less efficient even than 
removable plaster jackets. 




Fig. 162. — Leather jacket. 



34 2 ORTHOPEDIC SURGERY. 

ROUND SHOULDER JACKETS. 

Plaster-of-Paris jackets are sometimes used for rigid round should- 
ers, and the Lovett frame and the hammock frame are useful. 
The jacket includes the shoulders. Considerable force may be 
employed but pressing the shoulders forcibly back in such a jacket 
has resulted in temporary paralysis of the arm like a crutch paral- 
ysis. In covering in the shoulders considerable space is left behind 
over the scapular spines so that every few days, as the shortened 
tissues yield, the shoulders may be pressed farther back and held 
there by tucking more felt in front of the shoulder. Three to six 
weeks in one of these jackets makes a tremendous difference in the 
attitude of a patient. 

CLUB-FOOT. 

Plaster-of-Paris bandages are used for club-foot in different ways, 
first, for the gradual corrections of infants, second, for the gradual 
correction in successive stages employed by Wolff, and third, for 
maintaining the correction of club-foot after operation. 

Infant's Plasters. — Correction of club-feet by successive plaster 
bandages is easy in infancy and early childhood, provided, with 
patience and care, the patient can be humored and made docile. 
The only difficulty is holding it still in an overcorrected position 
while the plaster sets. To guard against pressure spots (babies will 
kick and disturb the setting of the bandage) it is necessary to envelop 
the foot and limb as far as the middle of the thigh very thickly with 
cotton batting. 

Narrow plaster bandages, two or two and a half inches wide, should 
be used; one may suffice for a small baby's foot. The writer prefers 
to apply a bandage as quickly as possible from the tips of toes to 
half way up the thigh, rubbing and holding it before the set actu- 
ally begins. This requires some speed with quick-setting plaster 
bandages and in older children where several bandages are required 
cannot be done. Success depends on holding the bandage after- 
ward; it should be done as follows: 

With the baby lying on the mother's lap the operator grasps the 



CLUB-FOOT. 343 

knee, raises the thigh vertical and bends the knee to a right angle 
in one hand, and with the other (left for a right foot), grasps the 
sole of the foot so that the thumb is on the inner border over the 
bunion joint and the pisiform bone comes opposite the cuboid, the 
palm of the hand presses the sole upward, the thumb turns the front 
of the foot outward, and the pisiform bone presses the cuboid upward. 
The position aimed for is an exaggerated calcaneo-valgus, with as 
much exaggeration as possible, — one cannot have too much. 

It is well to wind some cotton between the toes, removing it after- 
wards to prevent lateral compression, and to leave a soft cuff at 
the top of the bandage. A coat of shellac should protect a baby's 
bandage against wetting with urine. 

It is difficult to stop the infant's kicking, but if he be allowed to 
wave his arms and the other leg freely in the air, there is much less 
danger of his cracking the plaster than there is if he gets a firm 
purchase for them. 

Until overcorrection has been secured, the bandage should be re- 
newed every week or two afterwards once a month. Little tin shoes 
and splints of various kinds may be incorporated in the plaster 
for the correction of infantile club-foot. 

Wolff 's Correction of Club-foot. — Wolff corrects club-feet grad- 
ually or as he calls it by stages. He applies the first bandage with 
only a slight amount of correction; three days later he cuts the ban- 
dage in two around the ankle and removes from the outer and ante- 
rior border a segment like a section of an orange; he then corrects 
the foot so as to bring the cut edges of plaster together and applies 
a new plaster bandage to hold them there; three days later the 
same thing is repeated, and in the course of a few weeks complete 
overcorrection is obtained. He then covers the outside of the ban- 
dage with glue and shavings, attaches a wooden sole to it and allows 
the patient to wear it eight months, by which time he expects the 
bones to have altered their shape so that danger of relapse is over. 

The Plaster Bandage to Maintain Correction of Club-foot 
Obtained after Operation. — The plaster bandage should be applied 
from below the toes to well above the bent knee with the patient still 
under ether; the knee should be flexed as before, because if the ban- 



344 ORTHOPEDIC SURGERY. 

dage stops at the knee or if the knee is kept straight, varus correc- 
tion will be lost, for the plaster bandage turns around the leg as a 
rubber boot would. In holding the foot in plaster, the pronation, 
toeing out, and dorsal-flexion should be extreme and pressure should 
be made to prevent a descent of the cuboid. The tips of the toes 
should be exposed on the upper surface after the plaster has hard- 
ened so as to judge of the circulation. 

THE PLASTER SPICA BANDAGE. 

This bandage is very useful in giving rest to the patient in the 
acute stage of hip disease when he cannot get traction on a frame. 
For real rest the plaster bandage should extend from the tips of the 
toes to the axillae. 

The accompanying illustration shows a child on a pelvic rest with 
spica applied the rest is a vertical iron bar adjusted on the end of 
a table, bearing a flat plate of iron of No. 18 gauge, about three inches 
long by two inches wide, for children; a piece of felt on this 
gives enough softness to the sacrum and allows free handling 
ling of the patient while putting on the bandage. In private work, 
a support of some sort must be extemporized for the sacrum; 
usually a small box can be found and placed near the edge of a 
table and the patient's leg is held by an assistant; the leg and 
trunk are bandaged with sheet cotton wadding and the plaster ban- 
dages are applied at first from the knee to the umbilicus or the 
axillae. 

To strengthen spicas which almost always break at the groin, pieces 
of tin, strips of flat iron, or wood, are often incorporated. The writer 
has found the following method convenient: 

A wet plaster bandage is unwound, pulled, and folded together 
into a convenient length — about 30 inches; the whole is rubbed 
between the hands into a solid rope like a stick of molasses candy; 
it is then applied to the outside of the half finished spica, from just 
above the knee along the outer and lower side of the thigh to the crest 
of the ilium, then forward, gradually curving downward through the 
groin and down the anterior surface of the thigh almost to the knee ; 



THE PLASTER SPICA BANDAGE. 



345 



after which more plaster bandages are applied in circular turns about 
it and the whole rubbed together; one or two of these strengthening 
beams add greatly to the durability. 



THE PLASTER SPICA AFTER REDUCING A CONGENITAL DISLOCA- 
TION OF HIP. 

The pelvic rest of the spica support should be provided with a 
thick, vertical iron rod projecting about six inches above the plate; 
to serve both for counterextension at the perineum and as a post 
to attach turns of bandage to. The skin is protected with a layer 
of stockinette and with felt over the anterior spines and knee. The 
child, still under anaesthesia, is put on the support and the operator 
makes sure that the hip has not redislocated, that the attitude is 




163. — Support for applying plaster spicas. {Children's Hospital.) 



correct. One assistant holds the leg in position and steadies the 
pelvis, another supports the other leg and with the free hand rubs 
in the turns of bandage as they go on, the nurse wrings and passes 
the bandages as needed, and the operator stands in front to bandage. 
Three or four turns are first tightly applied around the pelvis imme- 
diately above the trochanter from the well to the affected side, then 
the bandage is brought over the anterior spine, the trochanter, and 
across the gluteal fold to the post; taking a turn around the post 
the bandage returns over itself to the anterior spine, and to the post, 
again a turn and the same is repeated ; by these turns firm inward and 



346 ORTHOPEDIC SURGERY. 

forward pressure is made on the trochanter; then some long turns 
are made from the crest on the well side over the affected knee and 
returning behind, which are held in place by regular spica turns, a 
few of which are made into a short spica on the other leg for still 
greater fixation. A plaster re-inforcement may be used on the 
front or back; if the position of Lorenz is used the knee is included 
and immediately after setting enough is cut from the popliteal space 
to permit knee- flexion; in the Mueller position, the hanging leg 
is enclosed in the plaster. The plaster may be bivalved, leaving a 
small piece uncut at the top and bottom of each cut and bandaging 
with a wet guaze bandage. The finished plaster shown in the 
illustration is applied in Mueller's position. Figure 36, page 53. 

The spica which Lorenz employs for hip disease goes from the knee 
to the waist. It is designed simply to restrict hip motions slightly. 
He encourages weight-bearing during all but the acute stages of hip 
disease. 

PLASTER-OF-PARIS CASTS. 

Casts are made both for a record and also to model splints on. 
The simple technique for taking casts of the hands, feet, legs, and 
backs, should be acquired, since the casts furnish the best possible 
record of deformities. Casts are needed for making plates for 
flat-foot, spinal braces for hump back, for making leather and 
celluloid jackets, etc., and for fitting artificial limbs. 

A Cast of the Back. — Casts are made with slow setting 
plaster. In order to obtain a shell mold of the back, the patient 
lies on the hammock frame, a table, or bed, suitably supported 
with cushions, the back is powdered with talc, and to and fro turns 
of plaster bandage applied until a shell has been made covering 
the desired portion about eight layers thick; this will harden in 
ten minutes, and is readily removed on account of the talc; plaster 
cream is prepared by adding, little by little, plaster to tepid water, 
stirring it gently to prevent bubbles; the shell, previously powdered 
with talc, is made horizontal and filled with the cream, and after 
hardening several hours, the shell and cast are easily parted. For 
a brace the outline may be marked on the back with an indigo pencil 



PLASTER-OF-PARIS CASTS. 347 

and enough indigo will come off on the bandage to transfer its mark 
to the cast for the workman to make his brace by. 

A Cast of the Trunk. — A plaster cast for a leather or a celluloid 
jacket is made by applying a snug fitting plaster jacket a little longer 
than required both at top and bottom; after setting, it is cut and 
removed with care; the cut edges are brought in contact and ban- 
daged; a stout piece of brown paper is then bandaged across one end, 
folded up over the sides, and held by some bandage turns; this 
mold is then stood with the paper side down in a tin mixing pan 
and is ready to have plaster paste poured into it. 

For convenience in making leather or celluloid jackets on these 
casts, a large wooden spindle, 2 X 2 inches, is usually left standing 
in the middle of the soft plaster which, after hardening, may be driven 
through the paper so that the cast can be clamped in a vise by the 
spindle, to hold it for carving or for the application of leather, 
painting with celluloid, etc. 

Casts for Flat-foot. — Various devices have been employed to take 
casts for flat-foot. The simplest method is to let the patient 
sit in a chair of such a height that the foot will hang in a pan of plaster 
cream until the plaster hardens. The impression of the sole of the 
foot should include the sides as high as the tubercle of the scaphoid, 
and as the tip of the external malleolus; powdering the foot 
with talcum prevents its sticking; coating the mold with the same 
and filling it immediately with plaster cream usually gives a good 
cast of the surface of the sole. In an hour or two it is hard enough 
to remove by chipping away the mold. 

The surgeon should feel the sole of his patient's foot so as to know 
how much soft tissue lies between him and the bones; remembering 
this, he later carves the cast to the shape of the plate which he desires 
to apply, cutting away from both the sides and bottom to allow for 
the compressibility of the soft parts and to make the plate narrow 
enough for the boot. 

The cast may also be taken by having the patient cross the knee 
and place the outer side of the foot on a stool on which is a sheet of 
cotton with the plaster paste; after the outer border of the foot has 
taken its permanent position, the cotton with the plaster on it is 



348 ORTHOPEDIC SURGERY. 

lifted up over the sole and inner border of the foot, until it hardens. 
The advantage of this method is that the foot is both relaxed and 
thrown into a position of cavus so that it is not necessary to carve 
away much from the bottom of the cast, only to trim the sides so that 
the plate will not be too wide for the boot. 



L 



CHAPTER XXI. 



LEATHER SPLINTS AND LEATHER JACKETS. 



Molded leather splints for the legs and arms are made on casts 
from bandages just as leather jackets are. They should be made 
of oak tanned English leather which is not "filled or stuffed." A 
paper pattern should be cut of the desired shape, the leather, cut by 
the pattern, is soaked in water until very soft, stretched over the 
cast and made to conform to every curve and depression by tacking 
one edge with a hammer, pressing the leather down to fit the hol- 
lows and fastening with tacks on the opposite edge after it is properly 
molded; or it may be adapted to the cast by tightly 
winding a small rope around it in close turns; or it 
may be tightly bandaged with webbing. Sometimes 
it is necessary to put something beneath the web- 
bing in order to force the leather into the hol- 
lows of the cast; it is then allowed to dry, either 
in the air which takes several days and depends 
on the condition of the atmosphere, or it may be 
baked at a temperature, not exceeding 120 F., 
which hardens and stiffens the leather; when 
thoroughly dried, hot bayberry wax is painted 
on until it will absorb no more. This leaves a 
dull non-absorbent surface which feels slightly greasy F IG i6 
to the touch. Strips of leather with lacing hooks, Short leather 
or eyelets should be sewed on the edge. Jackets or s P lca S P mt - 
splints may be shellacked three coats, which adds to its durability, 
by making it resist softening from the heat and perspiration 
of the body. The top and bottom of a jacket or splint may be 
protected by stitching a strip of soft sheep-skin on the edges but this 
is usually unnecessary; and any hard place on the border 

349 




35o 



ORTHOPEDIC SURGERY. 



which sticks in, can be softened by slashing into the leather 
little nicks close together and rubbing it until it yields. 

Unless great pressure is brought on them, these jackets and splints 
need no steels to re -enforce them. 

For the method of preparing casts for leather jackets, see p. 363. 

THE MODIFIED TAYLOR BRACE FOR CARIES OF 
THE SPINE. 



The brace consists of two uprights, a bottom piece or base, two 
shoulder pieces, and one or two cross bars. 

The uprights, vertical steels at either side of the spines, are curved 
to fit tracings of the spine made over the row of transverse processes 
with the child lying face down. The top of the uprights should be 
opposite the seventh cervical spine, and the lower ends an inch or 

more below the posterior superior 
spine of the ilium, provided the child 
is large enough so that both uprights 
may pass between the posterior 
superior spines without striking them 
and leaving f of an inch between. 
For smaller children they should end 
at the horizontal part of the base. 

For a child they should be made 
of malleable steel, J of an inch in 
thickness or a little less (No. 10-12 
gauge) and J inch wide, and be 
fitted exactly to tracings of the 
spine, it is well to fit them also on 
the back before they are riveted to the brace; opposite the deformity 
they should each have a thin steel pad plate, \ of an inch wider 
than the upright, shaped to fit the curve and if necessary to fit a 
curve across the back from side to side as well; each is attached by 
a single rivet at the top. Pad plates should be of spring steel, No. 22 
gauge, they may be wedged forward from the upright if any increased 
pressure is desired, and should be perforated close to the border 




Fig. 165. — The Taylor chest- 
piece or chest expander. 



LEATHER SPLINTS AND LEATHER JACKETS. 35 1 

with small holes to which a leather or a felt padding can 
be sewed. The bottom pieces may vary in shape; a U-piece is very 
often employed here, cut from a sheet of malleable steel, No. 12 gauge, 
with inverted limbs extending down on each side to a point be- 
low and two fingers' breadth within the inner side of the trochanters; 
on the tips are circular pad plates the size of a fifty cent piece, which 
are leathered; they should be low enough so that the patient can 
sit comfortably without striking upon the chair, that is about 
one inch above the level of the tuber ischii; the width between the 
tips of the U-piece should be the distance between the centers of two 
lines connecting on each side the trochanter and tuber ischii. 

The shoulder pieces are separate pieces, of malleable steel, the 
same width as the uprights, (No. 14-15 gauge or Yt °f an i ncn thick) 
which are riveted to the top of each upright and are bent outward on 
the flat at an angle of 45 and are bent over so as to conform to 
the root of the neck; in measuring, an inch or more is allowed below 
the top of the upright for riveting them on; anteriorly, they end at 
the forward edge of the trapezius. The cross bars, usually two, 
are a little shorter than the breadth of the trunk and usually 
one comes just below the posterior border the axilla, the other 
lower down; they should have the same width as the uprights, 
and be T V of an inch thick; all the parts should be fastened to the 
posterior surface of the uprights by stout steel rivets. For attaching 
the brace, straps and buckles are used which are fastened at appro- 
priate places by copper rivets; there should be one pair of buckles at 
the tips of the U, one at the corners, one at each end of the cross bars, 
and a webbing strap should be riveted to the tip of each shoulder 
piece. These buckles (tailor's buckles, 1 inch wide) receive the 
apron straps which are made of webbing f inch wide. The apron 
covers the anterior surface of the body and is made of stout cotton 
drilling or canvas; in width it extends from one posterior axillary 
line to the other, ending above at the axilla, and below at the sym- 
physis, the corners are cut away to allow for the action of the pec- 
torals above and below for flexing the thighs in sitting, but the apron 
must cover the anterior superior spines and one inch below them. 
To obtain a smooth fit, gores may be taken; wrinkling may also be 



35 2 



ORTHOPEDIC SURGERY. 



prevented by stiffening the apron at the waist with bones; the apron 
is made double and finished with a half -inch hem; webbing straps 
of suitable length to buckle into the brace are sewed on here. Rust- 
ing is prevented by nickle-plating the brace or bluing or japanning 
it. The skin of the back may be protected by felt or thin leather 
on the uprights, but it is better to have this protective material 





Fig. i 66. — Modified Taylor 
back-brace, old pattern with- 
out cross-bars and entire front 
leathered. 



Fig. 167. — Modified 
Taylor back-brace with 
oval ring head support, 
old style brace. 



only over parts where it presses most, the pad plates and waist band; 
when needed perineal straps padded with canton flannel or soft 
leather, they are fastened in front to buckles sewed an inch above 
the lower edge of the apron and behind are buckled to the tips of 
the U-piece. 

Any child with PoWs disease and forward shoulders needs in addi- 



LEATHER SPLINTS AND LEATHER JACKETS. 353 

tion a Taylor chest-piece; this consists of two triangular hard rubber 
or stiff leather pads made to fit under the clavicles and coracoid 
processes as shown in the illustration; they are joined together by a 
malleable iron rod made in two pieces so that it may extend or 
shorten; the pads are strapped to the shoulder pieces and to the first 
cross bar of the brace. 

HEAD SUPPORTS. 

The Taylor head support or oval ring is an attachment to this 
this back brace for caries higher than the seventh dorsal vertebra; 
it consists of an oval ring, a spindle and a socket. 

The oval ring extending from occiput to the tip of the chin, 
is slightly wider than the angles of the jaw, and is hinged opposite 
the right angle of the jaw to swing in a horizontal plane, and 
on the left is fastened by a pin and ring clasp. It is made of spring 
steel, \ by J inch; on the anterior part beneath the chin, a small tin 
plate is soldered, about ij inch wide and f of an inch long and to it 
is riveted a molded plate of hard rubber or celluloid to support the 
chin; at the back of the ring is riveted a piece of forged 
steel with a vertical hole to receive the top of the spindle which both 
supports it and permits of turning the head; on the inside 
here is attached a piece of stout leather which gives a soft agree- 
able rest for the occiput. 

The steel spindle which fits the hole in the ring is attached to the 
brace by a socket riveted to the two uprights of the brace;- it (the 
spindle) is bent to the curve of the neck so that the oval ring may 
support the occiput and chin at the proper angle. It is raised and 
lowered in its socket by two set screws. The spindle reaches from 
the occipital protuberance to % inch below the socket. It is forged 
out of soft steel, its lower part is | of an inch wide, and \ inch thick; 
it is flat on the anterior and round on the posterior surface; in its 
upper third it becomes circular, ending in a vertical circular pin 
which accurately fits a J inch hole in the socket on the back of the 
ring, and a small shoulder at the base of the pin prevents undue 
descent of the head support. 

The socket, a piece of machine steel, is riveted at each end to one 
23 



354 



ORTHOPEDIC SURGERY. 



of the uprights of the brace; it is sufficiently thick in the middle to 
have a hole through which the wide part of the spindle passes. 
Machine steel, J inch wide and f of an inch thick, is used. The 
dimensions for the hole are the same as those of the lower part of the 
spindle. Two set screws turning in threaded holes in the posterior 
half of the socket hold the spindle from slipping, fitting into depres- 
sions in its surface. 



WIRE CHIN REST. 

The wire chin rest is intended to be used with a plaster jacket or 
a steel brace. It is less efficient than the oval ring as a head support. 
It is made of a piece of wire and an occipital half band of steel. The 
wire is bent into a U-shape to rest upon the chest and shoulders 
and is sufficiently sprung forward to allow clear space over the clav- 
icles. The width between the 
vertical branches of the U is 
equal to the horizontal distance 
between the centers of the 
clavicles; in length they extend 
from the level of the xiphoid car- 
tilage to the border of the 
trapezius muscle. Here with a 
right angled bend the wire rises 
to a point just behind and 
slightly outside the angle of the 

jaw and there takes a right 
Fig. 168.— Wire chin rest. J , , r to 

angled bend forward and curves 

under the jaw to the chin. This apparatus should first be 
fashioned in flexible wire on the child, then duplicated in stout 
wire, jq of an inch (No. 5 or 6 gauge) in diameter, the ends 
of the wire should meet in the horizontal part of the U-piece on the 
chest, not under the chin. Around the right vertical part behind 
the angle of the jaw is wound an end of the posterior half-band of 
flat malleable steel, JXy^ inch, made to swing open like a hinge and 
shut close to the back of the neck; up and down movement is pre- 
vented by soldering a small shoulder on the wire below it. On the 




LEATHER SPLINTS AND LEATHER JACKETS. 355 

left, a small hook-shaped bend at the tip enables it to clasp itself to 
corresponding place on the left upright; one or two short wire rods 
riveted near the middle of this posterior band support pad plates 
for the occiput to rest on. Beneath the angles where the uprights 
rise at the base of the neck and extending for ij inches both for- 
ward and back of these points are soldered oblong pressure pads of 
thin steel or brass, f of an inch wide and 3 inches long; under the chin 
a small piece of tin is soldered to receive a hard rubber chin plate 
molded on a plaster cast of the chin like the one described in the oval 
ring head support. Under the horizontal part of the U and ascend- 
ing 3 inches upon either branch is soldered a strip of tin 2 inches 
wide lined with leather to give a broad flat bearing on the chest. 

A short webbing strap riveted to the under side of each shoulder 
pad plate fastens the apparatus to buckles on the shoulder pieces 
of the brace; from the right lower corner of the U-piece a strap 
passes around the body to buckle on the opposite side and secure 
the support from slipping sideways. Instead of the occipital pads 
on the posterior half band, the band may be thickly wound with 
felt or may have riveted to it a piece of jacket leather to support the 
occiput. 

When the wire chin rest is used with a plaster jacket two flat 
vertical uprights of malleable steel should be incorporated between 
the layers of the jacket, bearing each a buckle for the straps from the 
head support. 

THE GOLDTHWAIT HEAD SUPPORT. 

The Goldthwait head support consists of the upper part of a 
wire chin rest soldered on to a flat metal piece, \ inch wide by 
r V of an inch thick, which is to fit like a yoke on the chest and shoul- 
ders, extending down the back as low as the lumbar region. This 
gives a much firmer support to the head and shoulders but is more 
difficult to make on account of the peculiar curves in the flat 
metal yoke. To obtain a pattern for this yoke-piece a lead strip 
J inch wide is molded on the child so as to lie exactly where the yoke 
is to go. This is carefully removed, laid on its side and a profile 
tracing made from it. The lead strip is then carefully turned so 



356 



ORTHOPEDIC SURGERY. 



that a tracing may be made in its frontal plane also, after which 
it is flattened out and a paper tracing taken of the remaining curve. 
This tracing is then cut out of paper and placed on the child to see 
if it fits exactly in place and corrected so that it does so. Either a 
piece of flat malleable steel, \ inch wide and T Vof an inch thick, may 
be forged and bent hot to correspond with the curves of this piece of 
paper or the piece may be cut from a sheet and bent in the cold to corre- 
spond exactly with the curves in 
the two tracings, the one in profile 
and the one in the frontal plane. 
The wire portion is made exactly 
as for a wire chin rest without 
the part for the chest; instead at 
the base of uprights the wire 
runs forward 2 inches where it is 
cut off. These short ends, flat- 
tened and properly curved, are 
soldered to the yoke after trying 
it on and marking where they go. 
The apparatus is kept in place 
by a strap and buckle between 
the tips of the yoke and another 
from the same point encircling 
Fig. 169.— Goldthwait head support the body. It is applied by open- 




applied. 



ing the posterior half band, push- 



ing the ends of the yoke back on either side of the neck until the 
apparatus falls into its natural place then the neck band is clasped 
and the straps fastened. This apparatus with slight modifications is 
the one used for torticollis. 

THE TORTICOLLIS BRACE. 



The object of this brace is to keep the head in the overcorrected 
position after operation. The Goldthwait head support is used at 
the Children's Hospital for this purpose. It has to be modified 
slightly to suit this deformity. The modifications affect the 



LEATHER SPLINTS AND LEATHER JACKETS. 



357 



wire portion only, the yoke remains the same. The wire support 
under the chin should be made to hold the head looking to one side, 
instead of straight forward. The hard rubber cup for the chin 
must be enlarged so as to press on one side of the chin to maintain 
position, and an upright with a pad plate is riveted to the posterior 
neck band so as to press upon the parietal boss on the side of divided 




Fig. 170. — Support 
for torticollis. 




Fig. 171. — Same applied. 



muscle. This will be readily seen by reference to the accompany- 
ing illustration. The object of the brace is to maintain the ends of 
the divided muscle as far apart as possible. 



THE THOMAS COLLAR. 

The original Thomas collar was a strip of soft calf skin sewed 
at the edges into a tube and stuffed with saw dust. The diameter 
was greatest under the chin and smallest under the ears and it was 
fastened together with two small straps and buckles at the back of 
the neck. A greater or smaller amount of saw dust increased or 
diminished the amount of support. Such a collar can be made by 
any saddler, but it is somewhat clumsy. A similar support may be 
made by winding upon a webbing strap or a piece of bandage, alter- 
nate layers of oakum and bandage; or a central core of stiff leather 



358 



ORTHOPEDIC SURGERY. 



or card board cut to shape may be wound thickly with oakum and 
bandage. Stiffened leather, woven-wire netting, aluminum, and 
celluloid collars may be made on a cast of the neck and shoulders 
just as a leather jacket is. The Thomas collar may be used effi- 
ciently with a plaster jacket, if the jacket extends over the shoulders. 

THE QUADRILATERAL BACK BRACE. 

The quadrilteral back brace was designed by Dane to combine 
the efficient antero-posterior support of a back brace with the preven- 
tion of side bending secured by the 
plaster-of-Paris jacket. The uprights 
are here separated so that they rise 
vertically over the angles of the ribs. 
Pressure on the transverse processes at 
the point of deformity is obtained by a 
detachable transverse band, bearing 
pad plates. 

The pelvic band of No. 15 gauge 
cast sheet steel is bent to fit across the 
back at a point just above the tro- 
chanters. It ends on each side close 
behind the anterior superior spine and 
slightly below it. 

The uprights, of No. 12 gauge flat 
steel a half inch wide are riveted to the 
upright, well outside of the posterior 
superior spines; they rise vertically over 
Fig. 172.— Dane's quadrilat- the angles of ribs to end a finger's 
eral brace. Note abscess from breadth above the spines of the scapulae 

where the descending arms of the top 
bar are riveted to them; the uprights follow the curves of the flank 
but do not press hard upon the skin over the lower angle of 
the scapula, but do press on the rest of that bone when the 
shoulder straps are tightened. The length of the top bar is the dis- 
tance between the glenoid cavities of the scapulae with the shoulders 
fully back; its ends are bent at a right angle downward and are 




LEATHER SPLINTS AND LEATHER JACKETS. 359 

continued downward one additional inch for riveting on to the 
uprights. 

The Pad Plate Bar. — This is a horizontal bar of half-inch flat 
steel, No. 14 gauge, secured to the uprights by screws at the level of the 
kyphos. In the middle is a small backward curve to clear the spin- 
ous processes and beside that curve are the pad plates of No. 18 
gauge sheet steel, \ inch wide and 3 or 4 inches long, so shaped as to 
press exactly upon the transverse processes. To facilitate adjusting 
this bar the screws that hold it to the uprights pass through slots 
instead of round holes; this bar requires very careful fitting with 
wrenches. 

From each upper corner of the brace two webbing straps pass, 
one round the shoulders buckling to the side of brace, and one to the 
front of the apron. On each side two side straps from the apron 
fasten in buckles on the uprights, and one to a buckle on the end of 
the pelvic band. The apron is made of jacket leather T V to \ of an 
inch thick; it should extend from the level of the ensiform to the top 
of the pubis in the median line and from same level to an inch be- 
low the anterior superior spines on the sides. Webbing straps are 
sewed to it opposite the buckles and brace. 

The head support for this brace consists of two flat uprights which 
are adjustable vertically by means of sockets and set screws on 
the top bar and the pad plate bar, a strap or sling for the occiput, 
and a strap for the forehead. The uprights are flat malleable steel 
bars, J inch wide and y 1 ^ of an inch thick, starting 1^ inches below 
the pad plate bar, they are left perfectly straight until a finger's breadth 
below the occiput, where they are forged into round rods, curving 
upward and outward to a point an inch above and J inch behind the 
ears, where they turn forward horizontally close to the head as 
flat bars, ending at the edge of the hair, where the buckle is riveted 
on each side for the forehead strap. The occipital strap is riveted 
to one of the uprights at the angle where it becomes horizontal, 
it buckles at a corresponding place to the other upright. It is rein- 
forced on the outside with a thin strip of brass | of an inch wide to 
prevent curling. The frontal strap is of calf skin, one inch wide 
where it crosses the forehead, tapering to fit the buckles. 



3 6 ° 



ORTHOPEDIC SURGERY. 



THE WRITER'S MODIFICATION OF TAYLOR'S BACK BRACE. 



This brace, originally intended for the correction of rigid round 
shoulders, has been in use for five years at the Children's Hospital, 
for Pott's disease of the lower dorsal and dorso-lumbar spine. It is 
designed to avoid displacements from muscular effort, to encourage 
free chest and lung expansion, and to hold the dorsal spine in a posi- 
tion where nature locks it against all lateral 
and rotary movements. The uprights are 
fashioned precisely as for the Taylor back 
brace and are placed directly over the 
transverse processes, the space between 
uprights rarely exceeding an inch in chil- 
dren. Pad plates are used. 

The bottom piece covers most of the 
sacrum and rises so as to follow close 
below the iliac crests to a point behind 
and below the anterior spine. This shape 
conforming to the outer surface of the 
ilium just below the crest covers a space 
where the muscles are thin, and by their 
contraction cause very little displacement. 
The lower cross bar of the brace is made 
to fit the loins just above the iliac crest, 
and prevents sagging down of the brace. 
The upper cross bar is placed below the 
tips of the scapulae. 

At the top the uprights are riveted to 
a plate an inch wide and 3 inches across 
so that it projects at least a half inch outside of the uprights. To 
this are loosely riveted movable shoulder pieces of 16 gauge steel 
cut L shaped. The angle of the L comes behind the glenoid cavity 
when the shoulder is back and the lower end descends 3 or 4 inches 
and curves forward into the axilla so that the axillary strap from its 
end which encircles the shoulder and buckles to the angle of the 
L cannot possibly press upon the axillary vessels and nerves. The 




Fig. 173. — Brace for rigid 
round shoulders. 



LEATHER SPLINTS AND LEATHER JACKETS. 



361 



short arm of the L is loosely attached by a rivet in the outer border 
of the plate so as to allow a little movement. 

The apron may be of leather or cloth ; it extends from the breast to 
the symphysis in the median line and on the sides from just below 
the anterior superior spine to a point in the middle axillary line op- 




Fig. 174. — The same applied for dorsal caries. 

posite the upper cross bar. Straps attach it to buckles on the pelvic 
band and cross bars and an additional strap is often needed at the 
waist. 

THE FLEXIBLE OR SPRING STEEL BRACE. 
When employed for round shoulders, the plate, movable L pieces, 
and axillary straps may be used on top of a light flexible spring steel 



362 ORTHOPEDIC SURGERY. 

brace. This flexible brace is also used at the end of the convalescent 
stage of Pott's disease and affords a slight protection to the spine. 
It is made usually of a horizontal pelvic band which encircles the 
posterior part of the pelvis ending on each side at a point one 
inch behind the anterior superior spines. This should not be made 
out of a straight flat piece of metal ; a paper pattern should be fitted 
on the child to get the proper curve, and it is cut from 16 gauge sheet 
steel 1 1 inches wide. The uprights extend from it an inch to ij 
inches apart vertically to the level of the first dorsal spine, where they 
bend outward at an angle of 45 extending as shoulder pieces for about 
2 inches; the space between the uprights should be 1 inch at the top 
and 1^ inches at the bottom. They are made of No. 16-18 gauge 
spring steel \ or § of an inch wide; and should be bent to follow 
the general outline of the back only; the lumbar curve is much 
exaggerated and the upright is spring tempered. A cross bar \ 
inch wide is riveted to the uprights an inch below the posterior axil- 
lary folds; it should be 1 inch less on each side than the width of the 
back and shaped to avoid pressing on the scapulae. Holes are drilled 
for buckles at the ends of cross bar and of the base band. Straps 
connect the tips of the shoulder pieces to buckles at the ends of the 
cross bars; they should be padded with soft leather. Where the 
abdomen is protruding, a leather abdominal band, 4 to 5 inches 
wide, should be sewed to each upright at the waist and made to 
fasten in front with straps and buckles. 

BRACES FOR LATERAL CURVATURE OF THE SPINE. 

The variety of braces which have been used for the treatment of 
this deformity is very large. At the Children's Hospital, the 
one at present in vogue was devised by Keen, of Boston. It is a 
modification of many others. 

The brace consists of a horizontal pelvic band similar to that last 
described. An upright in the middle of the back extends to the verte- 
bra prominens and a lateral upright from the front of the pelvic band 
to the anterior part of the axilla on each side. Two posterior half 
bands, one at the waist and one at the top, convert this into a close 
fitting posterior shell into which the trunk is strapped. 



LEATHER SPLINTS AND LEATHER JACKETS. 



363 



REMOVABLE JACKET FOR LATERAL CURVATURE. 

Removable jackets for lateral curvature are to be modeled, not on 
the cast of the patient, but on that cast after it is carved and corrected 
to suit the requirements of the case. This must be done by the sur- 
geon; he can do it better with the patient's bare back before him. 
Humps from backward rotation of the ribs are 
smoothed down, or shaved off with a chisel or 
draw knife, and he builds up the unnatural hollows 
with fresh plaster paste until a back with the 
required amount of correction has been fashioned 
in plaster on which the jacket is to be made. 

When the jacket so prepared is applied and 
worn it is often desired to obtain still more an- 
terior pressure or side pressure on the rib hump 
and to allow more room over the depressions. 
This may be accomplished by cutting out a piece 
of the jacket over the rib hump and strapping it 

into place again so as to exert on the hump 

... . ... . Fig. 175. — Leather 

strong strap pressure which may be varied by the j ac ket for lateral 

direction of the straps and buckles; over the de- curvature made 
... ril . . over corrected cast, 

pressions which are to nil out windows may 

cut and left open. 

The same principle is used in the brace. 




APPARATUS FOR LATERAL CURVATURE DESIGNED TO 
ALLOW RESTRICTED MOVEMENTS IN THE BACK. 

Wullstein, who probably applied forcible correction with greater 
force than anyone, except Calot devised a brace with a head support, 
constructed so that some movement is permitted in the lumbar spine 
by inserting in the upright spiral springs made of a flat steel 
rolled like a paper alumette. His brace consists of a base made 
of a pelvic girdle of leather, reinforced with a metal pelvic band and 
two metal strips over the iliac crests which constrict the pelvic band 
slightly, just above the crests. The spiral springs, are attached to 
the pelvic band, 1 J inches apart, and to the upper ends of these, vertical 



364 ORTHOPEDIC SURGERY. 

flat steel uprights bearing at the level of the shoulder-blades a cross 
piece to support the arms. Attached to the cross piece and to the 
metal uprights is a moulded leather pad to press on the rib hump so 
that pressure can be increased from time to time. The spiral springs 
permit movement in the lumbar column, and at the level of the atlas 
a joint with limited motion allows slight rotary movements of the 
head. The flattened part of the thorax opposite the rib hump is 
left free but the anterior rib hump receives the pressure of leather 
straps arranged not to press upon the opposite side of the chest, while 
the forward pressure on the posterior rib hump is regulated by a 
modeled leather pad and set screws. 

The head piece, made on a cast, covers the entire occiput and 
half of the squamous bones. The head is secured in it by a broad 
forehead strap. The chin is left free. As much pressure may be 
applied to the trunk in this brace as the patient can stand. 

HIP SPLINTS. 

The traction hip splint used at the Children's Hospital is a 
modification of that of C. Fayette Taylor, of New York. 

It consists of an upright, a foot piece, a waist band, two half bands 
for the thigh and one for the calf. 

The upright is a square steel rod connecting the waist band and 
foot piece, the latter ends three inches below the heel and the upright 
runs from it to a point in the line of the leg opposite the anterior su- 
perior spine; it may often be a straight rod but as often it has to be 
curved to fit the thigh and knee, which is done by bending it to con- 
form to a paper tracing of the limb; sometimes the lower end is 
half rounded and is perforated with screw holes to attach to an 
adjustable foot piece, and sometimes it is itself prolonged into a foot 
piece by forging two right-angled sharp bends after first flattening 
the lower six inches to a width of f and a thickness of J of an inch ; 
the upper end is flattened out by forging into a small oval plate to 
be riveted to the waist band; this oval is about ij by f or § of an 
inch, with the long axis not at a right angle to the rod, but mak- 
ing an angle of seventy degrees with the front of the upright. yV, f, 



HIP SPLINTS. 



365 



and yw are the sizes of rods for little and medium children and 
adolescents. After forging and bending to shape, the upright is 
heated and tempered to make it rigid. In the oval plate at the top 
three rivet holes (J- inch) are bored and, if an adjustable foot piece 
is to be attached, seven threaded holes for one-eighth inch machine 
screws are made a half-inch apart. 

The adjustable fool piece is forged from the same metal eleven inches 
long, the upper end is flattened into an oval and the projecting sides 
turned up to clasp the half round upright; it 
is perforated with a row of screw holes. In the 
lower half it is forged f inches wide, and \ of an 
inch thick; three-fourth inch is then turned over 
at the end at a sharp right angle and a similar 
angle is forged 2\ inches farther up to form the 
foot piece. A \ inch hole is bored in the turned 
up end \ inch above the ground, and one in 
the upright opposite to it for the windlass spin- 
dle. The latter 3J inches long, J of an inch 
in diameter, is squared at one end and is held 
in place by a pin through it inside of the pro- 
jecting part of the foot piece. It projects be- 
yond the outside surface of the upright for \ of 
an inch. Outside next to the upright there is 
attached to it a half-inch ratchet wheel, which 
is controlled by a spring and stop 1} inches 
long, fastened to the upright by pins. The 
projecting square end of spindle is made to lit a 
clock key. The center of the spindle is filed 
half way through on one side and a slot cut out 
and in from this point to within \ of an inch of the foot piece to 
receive the webbing straps of the extension. 

The waist band is made of flat steel one inch wide, called tire steel, 
No. 8 gauge. The posterior half is one inch longer than the anterior 
and is bent in a more gradual curve ; the anterior half must be care- 
fully fitted. It extends from the middle of the outside of the thigh 
above the trochanter to a point just over the opposite anterior supe- 




Fig. 



176. — Traction 
hip splint. 



366 ORTHOPEDIC SURGERY. 

rior spine. It is forged so that the anterior and posterior arms are 
parallel to each other in vertical planes when the waist band is 
inclined 20 to horizon. The waist band is fastened to the flat 
oval top of the upright, with the posterior arm higher, by three stout 
steel rivets. In large heavy patients this is sometimes insecure; and 
for. them the upright should be left square and a piece of machine steel 
is prepared to fit round it and extend ij inches along the waist band 
in front of and behind it. A 3^- inch rivet holds this forged piece, 
the upright, and the pelvic band together and similar rivets attach 
the forged piece and waist band in front and behind, making it 
very strong. Buckles are fastened to the pelvic band, outside of the 
leather padding, two in front and two behind, for the perineal straps. 
At the back they should be half way between the trochanters and 
the posterior superior spines. In front they should be closer together 
but leave ample room for the genitals. Another buckle attached 
to the anterior end of the pelvic band receives the belt strap. The 
waist band is lined with felt and covered with soft leather stitched at 
the edges; at the posterior end this leather is prolonged into a belt 
to go the rest of the way round the waist, or a strap of jacket leather, 
1 J inches wide, is riveted there which buckles to the end of the 
anterior arm. 

Posterior Half Bands to Secure the Leg in the Splint. — Generally 
three bands are used in older children, two in small ones — one at the 
middle thigh and the other at the upper third of the calf; they enclose 
half the circumference of the leg and the strap holds the rest. These 
are strips of steel, No. 14 gauge, 1 inch wide; fastened to the 
inner side of the upright by soft pieces of steel similar to 
that described for attaching a pelvic band for heavy patients, but 
smaller, and fastened by screws which may be loosened to ad- 
just up and down on the upright. These bands are padded with felt 
and covered with thin leather; to the free end is riveted a webbing 
strap to pass around the leg and buckle to the band behind the 
upright of splint. 

Perineal bands are made of webbing wound with canton flannel; 
or, leather may be used, padded with felt, and covered with chamois 
or moose-hide. For children who habitually soil them, a webbing 



HIP SPLINTS. 367 

strap may be passed through a rubber tube about \ inch in diameter 
which gives padding enough. As these straps are worn under ten- 
sion one must take care to prevent the skin from chafing and to guard 
against pressure sores. The stitches in the canton flannel must be 
away from the skin, the straps are to be loosened two or three times 
a day and the parts bathed in alcohol and powdered with talc. 

The splint is used with a high sole on the well foot, and crutches, 
and it swings clear of the ground in walking. 

CONVALESCENT HIP SPLINT. 

The convalescent hip splint is usually made out of the patient's 
old splint. The lower end may either be arranged to fit in a steel 
socket fastened to the shoe and projecting upward on the inner side 
of the foot; or, a simple end like a crutch tip may be forged on to rest 
on the ground. This splint, designed to allow the patient to walk 
upon the toes, makes it impossible to touch the heel to the ground 
or to pound his weight upon it. To convert the lower end of the trac- 
tion splint into a convalescent one, it is cut 3 inches from the ground 
and there is welded to the upper part a piece long enough to extend 
2 inches below the sole of the boot, where it expands into a bulbous 
tip } of an inch in diameter, over which a crutch rubber may be 
stretched. The total length of the splint should be the distance from 
the anterior superior spine to the bottom of the heel of the shoe with 
the foot at right angles plus ij inches. If it be desired to have a 
splint of adjustable length, after cutting off the lower end of the up- 
right, it is forged flat on inner side, and rounded on the outer, and 
is perforated with threaded holes i inch apart to receive the set 
screws from the adjustable foot piece. The upper end of the latter 
is drawn out into two small clips curving slightly inward to em- 
brace between them the rounded part of the upright so that the 
foot piece can slide up and down, and is perforated with screw 
holes ^ inch apart. The screw holes are brought opposite each 
other and the foot piece screwed to the splint by machine screws. 

When a convalescent splint with a socket in the shoe is pre- 
ferred, the old splint should be cut off an inch above the ground, and the 



3 68 



ORTHOPEDIC SURGERY. 



upright flattened out till it is § or f of an inch wide for a space of 2\ 
inches; a slot is then filed or cut out from the end running from before 
backward, \ of an inch wide, extending \\ or \\ inches upward, 
and a pin f of an inch wide is riveted into it for the socket to 
turn on. 




Fig. 177. — Con- 
valescent hip 
splint with crutch- 
tip end. 




Fig. 



178. — Convalescent splint 
with socket on shoe. 



The foot piece made like that for bow-leg irons is similarly 
attached to the shoe, the upright rises at right angles verti- 
cally, 2\ inches. The plate and upright are made of -^ inch 
sheet steel and the upright should be at least an inch wide with a 
deep notch as shown in the figure to receive the pin of the upright. 






HIP SPLINTS. 



369 




CONVALESCENT HIP SPLINT JOINTED AT THE KNEE. 

This splint carries a single perineal strap buckled to the extremity 
of short anterior and posterior arms. The upright at the knee 
curves backward and has a hinge joint opposite the posterior 
borders of the condyles. The hinge is stopped to allow 
free bending forward at the knee but prevents back 
bending beyond a straight line, and the center of mo- 
tion is far enough behind the line of weight to lock the 
splint securely without catch. 

THE DANE HIP SPLINT. 

This splint consists of a Thomas knee splint with a 
windlass and ratchet for extension at the base and with 
the waist band of a traction hip splint fastened to the 
top above the ring. The object is extension combined 
with more fixation than obtains with webbing perineal 
straps. For counter-extension, he substitutes on one 
side the ring of the splint as a rigid support to the 
perineum and in place of the other perineal strap uses 
a chain covered with felt and chamois skin. The con- 
struction may be readily seen from the accompanying 
illustration. It differs from the ordinary Thomas knee splint in 
having a stouter upright on the outer side, a windlass and ratchet 
in the foot piece and a waist band. 

To fix the pelvis Dane later altered the waist band by adding 
to it a second posterior pelvic arm which is carried as low down as 
possible over the sacrum. These arms are prolonged along the sound 
side of the pelvis by spring steel strips riveted to a broad leather belt. 
A firm grasp of the pelvis is thus obtained and movements of the hip- 
joint are in large measure prevented. It is an excellent splint but 
demands care in fitting to prevent sores on the perineum from pres- 
sure. 

THE THOMAS HIP SPLINT. 

This splint is designed to fix the hip-joint and does not contemplate 

extension. It has an upright, a chest band, a thigh and a calf band. 
24 



Fio. 179. — 
Convalescent 
hip splint 
jointed at the 
knee. 



37° 



ORTHOPEDIC SURGERY. 



The upright extends vertically in the line of diseased leg and up 
the back from the junction of the middle and lower third of the leg 
to the lower angle of the scapula. It has two bends, one opposite 
the fold of the buttocks, the other just above the hip- joint, so that 
the leg part and the body part are in parallel planes; the lower part 





Fig. 



180. — Dane's hip 

splint. 



Fig. 181. — Bradford's abduc- 
tion hip splint applied. 



from the fold of the buttock to the lower end of the splint is from a 
half inch to 2 inches anterior to the upper; the upper portion conforms 
slightly to the curve of the back but is nearly straight. It is usually 
necessary to twist the upright slightly on its longitudinal axis so that 
the body portion conforms to the rounding of the side of the chest, 



HIP SPLINTS. 



371 



while the leg portion is in the middle line of the thigh and leg. The 
bent portion for the buttock extends from the level of the trochanter 
to that of the tuberosity of the ischium. A child of 10 requires an 
upright I of an inch wide and ^ of an inch thick, of toughest and 
softest iron. 

The chest piece is made of strap iron: its thickness (No. 14-18 gauge) 
and width vary, according to the patient's size. It should be 
long enough to encircle the chest, leaving a gap of 2 inches between 
the ends ; it is fastened to the upright, not in the middle, but enongh 
to one side to bring the gap over the front of 
the chest in the median line. If riveting is 
not sufficiently secure, the upper end of the 
upright may be flattened and bent down 
over the chest piece, then the two are made 
fast by a rivet. The ends of the chest piece 
are flattened out and a hole f of an inch in 
diameter drilled for fastening the shoulder 
bands. The upright and chest piece are at 
right angles to each other. The thigh band 
is made of strap iron of the size of the chest 
band and fastened to it an inch below the 
bend, in such a way that the inner portion of 
the band is 1 to 2 inches shorter than the 
outer. The calf band of strap iron also is 
fastened to the bottom of the upright by a 
single rivet. The part of the splint next to 
the patient is covered with thick felt, and 
a covering of sheep-skin may be stretched on wet. 

The final fitting of the splint to the child is done with wrenches 
until the bands fit closely to the leg and chest. The leg is 
bandaged to the splint and suspender straps pass from the top 
of the upright over the shoulders to the holes in the ends of the 
chest piece. 

The Thomas hip splint gives fixation without traction. When 
properly applied, it gives the best sort of fixation. It should be worn 
continuously for months and only removed at long intervals by the 




Fig. 182.— Bradford's 
abduction hip splint. 



37 2 



ORTHOPEDIC SURGERY. 



surgeon with plenty of assistance, so that the hip is prevented from 
making the slightest possible movement during removal and until it 
is reapplied and secured. Weight-bearing on the effected limb is 
prohibited, but except during exacerbations the child may walk on 
crutches, with a high sole under the well foot. 

The Thomas hip splint for double hip disease is similarly 
made and fitted, but the uprights are attached to a single chest band 
and are connected at their lower extremities by 
an iron rod of suitable length to keep the feet 
about 12 inches apart. It should be most care- 
fully padded as it is used to secure rest in the 
recumbent posture. 

TUBULAR HIP SPLINTS. 

For little children under 5 years of age the 
writer uses a traction splint with an upright of 
steel tubing, because it is stifler and lighter than 
a small steel rod. The upright consists of a 
piece of steel tubing T 7 g- or J inch in diameter 
into the upper part of which is brazed a forging 
similar to the flattened end on the upper part of 
the upright of a traction splint; into the lower 
end slides a rod which below is forged into a 
light foot piece while the upper portion of the 
rod, for 6 inches, is threaded and carries two 
nuts. The rod sliding in the tube almost fills 
it ; a slot in the tube permits fastening a pin into 
the rod to prevent the foot piece from turning 
around. Straps for the foot piece, the posterior 
half bands, and the thigh bands are suitably attached, and the waist 
band does not differ from that of the ordinary traction splint. By 
strapping the leather straps of the foot piece into buckles on the leg 
extension, and turning the nuts, the foot piece is protruded from 
the tube and exerts traction against the counter-extension of the 
perineal bands. 

Tubular splints have been made by other surgeons in various ways. 




Fig. 183. — Cheap 
tubular hip splint 
made of gas pipe. 



THE THOMAS KNEE SPLINT. 



373 



The Gas Pipe Splint. — Avery cheap traction splint was made by 
Wilson out of f inch steel gas pipe. The lower six inches are flat- 
tened in a vise and given the proper bends for a foot piece; the top 
is screwed into a Tee bearing the anterior and posterior arms of the 
waist band, also made of flattened tubing. Its cheapness commends 
it, but it is not durable. 

THE THOMAS KNEE SPLINT. 



The Thomas knee splint is a perineal crutch; it consists of a rigid 
ring for the top of the crutch and two lateral 
uprights joined together in a foot piece. 

The ring is made of round steel wire, 
No. 5 gauge for children; No. 3 for adults; 
with the ends brazed together or welded. 
The shape is an irregular ovoid and ap- 
proaches a right-angled triangle. The front 
is flat, the back bulging ; it slopes down both 
from within outward and from before back- 
ward. It is fastened to the inner upright by 
brazing, at an angle of 135 . The anterior 
surface of the ring is flat to conform to the 
groin; the posterior part expands to support 
the tuber ischii and conform to the thick- 
ness of the buttock. The posterior part is 
made lower than the anterior to enable the 
patient to rest the tuberosity of the ischium 
comfortably on the ring. The measurement 
for the ring is the oblique circumference 
of the thigh at the perineum taken one inch 
below and parallel to the fold of the groin, 
to which 1 \ inches should be added to allow 
for the padding. 

The uprights are made of round steel wire 
adult; No. 2, 3, or 4 gauge for a child 
ring by brazing. The outer rod 




—Thomas' knee 
splint. 



No. i. for an 
They are secured to the 
is fastened to the ring slightly 



374 ORTHOPEDIC SURGERY. 

farther back. The bottom of the rod should be 2 or 2\ inches 
below the sole of the bare foot. As originally made, the inside 
upright curved around under the foot to become the outside upright, 
but for walking, foot plates are better; they are made of vari- 
ous patterns and are brazed on. A large iron washer J of an 
inch thick attached to the uprights makes an excellent foot piece; if 
shod with a piece of sole leather. The length of the inner upright 
is the distance from the tuberosity of the ischium to the sole of the foot 
at right angles to the leg with 3 inches added. The width at the knee 
and ankle should be given the workman as well as the size of the 
ring, and a tracing of the leg. The ring is padded with felting \ inch 
thick at the outer part and from 1 to ij inches thick on the inner 
and posterior sides; the felt is tightly covered with thin calf or tanned 
sheep-skin applied wet and sewed after the manner of harness makers 
along the lower border of the ring where the seam cannot chafe the 
skin. Various methods of securing the leg in the splint are in 
use. Two pieces of leather, 4-6 inches wide, sewed to the outer 
upright, and loosely surrounding the inner and the limb are used 
to lace the thigh and leg into position; or, with a broad strap be- 
hind knee and ankle the leg is secured to the splint by a band- 
age; and where the knee is slightly flexed a leather knee cap with 
straps and buckles at the four corners may exert corrective pressure 
backward. 

Thomas used to bandage the splint tightly behind the calf of the leg 
with a roller bandage, but above the knee he tied his bandage 
to one upright, carried it over the thigh, under the other upright, 
over the thigh, under the upright, etc., until at the knee the bandage 
exerted considerable corrective force to extend the joint. Broad 
leathers attached to one upright with lacings and hooks have already 
been spoken of; they are best made from paper patterns cut to 
suit each case. The leather knee cap should have a hole to avoid 
pressing on the patella and extend an inch above and below it; at 
each corner is a buckle and strap to encircle the upright and return 
to the buckle. If the knee hyperextends a 3-4 inch leather strap is 
sewed across between the uprights and the knee cap presses the knee 
back on to it. 



THE THOMAS KNEE SPLINT. 



375 



thomas's caliper splint. 

For those who can be allowed to walk on the toes, the caliper 
splint may be used. Those who have reached this stage may have 
their old knee splint converted into a caliper splint by sawing off 
the foot piece from the uprights and 
bending the last inch sharply inward 
at a right angle. It is best to apply 
the unfinished splint in its proper posi- 
tion and mark upon the uprights the 
place for bending, which should be 
such that the heel is kept an inch 
above the heel of the boot. 

The splint consists of the ring and 
uprights of the Thomas knee splint 
which are bent below at right angles 
to fit in a steel tube in the heel of the 
boot. The bends should be an inch 
long, and a leather strap around the 
ankle prevents the uprights slipping 
out from the tube. Either a knee cap 
may be employed, or wide thigh and 
calf leather lacings. Where the heel 
strikes against the back of the boot it 
sometimes excoriates, in which cases 
a triangular piece of leather should be 
put in the back of the shoe for the heel 
to play on, and it is sometimes neces- 
sary to slit the back seam just above 
the counter for a short distance. The 
splint may be nickeled, blued, or 
japanned. 

A similar splint is often used for infantile paralysis to keep weak 
knees from bending; but the Thomas ring is unnecessary, and a 
posterior half band of steel, i£ inches wide, is substituted, the 
splint ending below the gluteal fold. Where toe-drop or calcanous 




Fig. 185. — Thomas' caliper 
splints for infantile paralysis. 



376 



ORTHOPEDIC SURGERY. 



interferes with walking an ear, three-quarters of an inch long by a 
quarter wide, is left in cutting off the steel tube, which is turned up- 
ward after putting it into the boot heel so as to strike the upright and 
stop further motion. For toe-drop ft is placed behind, for toe-rise 
in front of the upright. 

FIXATION ANKLE SPLINT. 

This splint, used for fixation and protection of the ankle-joint 
after operations, arthrodesis, and tendon transference, consists 
of two uprights, a foot piece, and a posterior calf band. For the 





Fig. 



— Fixation 
splint. 



ankle 



Fig. 



187. — Same splint to show 
leathers. 



uprights, one continuous piece of steel may be used, f to f of an inch 
wide by | thick, attached to the foot piece with a right-angled bend 
on either side; these bands must be shaped sufficiently not to 
touch the foot on either side; the malleoli especially must not touch 
them. They are riveted at the top to a posterior calf band, curved 
to fit the posterior half of the calf, made of No. 16-17 steel, an 
inch wide. 

The joot piece is a plate of sheet steel of No. 14-16 gauge forged 



KNOCK-KNEE IRONS. 377 

roughly to the shape of the sole of the foot from the toes to the heel. 
It should be \ of an inch narrower on each side than the whole width 
of the foot and should stop \ inch in front of the back of the os calcis 
and should be riveted on top of the horizontal part connecting the 
two uprights. 

Leathers and Buckles. — The calf band is padded with felt 
and covered with leather ending in a strap to buckle around 
the front of the leg. A piece of soft leather, cut by pattern like 
the upper of a low shoe, covers the foot from behind the 
metatarso-phalangeal to the ankle joints, leaving the point of the heel 
uncovered; it is riveted by its sole to the sole plate. The two flaps 
meet over the top of the foot and lace down the middle with a fly 
like the tongue of shoe to prevent pressure from the lacings. The 
posterior part of this foot leather is sewed by a vertical seam 
behind so to fit snugly over the tendo-Achillis. The sole piece of 
the brace may be made lighter if the weight is not to rest upon it. 
It is often used with a Thomas knee splint to maintain a correct 
position of the ankle, which otherwise might get stiff in the position 
of toe -drop. 

KNOCK-KNEE IRONS. 

The knock-knee brace consists of an upright and a foot piece. 

The upright is made of malleable steel, tempered, \ inch wide and 
tV of an inch thick, and extends vertically from a point opposite the 
ankle-joint to the top of the trochanter, where it bends upward and 
backward to end just below the posterior superior spine of the ilium. 
The bottom of the upright is flattened and enlarged and has a 
\ inch hole, for the spindle of the ankle-joint. 

The base piece is divided by a right-angled bend into a sole part 
and a vertical piece. The sole part is a triangular piece of the same 
steel nearly as wide as the boot heel and terminating in front in a 
broad rounded point. It should be if inches long and a little less 
wide than the shoe. At its outer border the verticle side piece 
begins as an arm of the same size and width as the lower end of the 
upright; to which it is connected by a joint opposite the child's 
ankle. It is curved out to avoid the ankle and a pad, the 



378 



ORTHOPEDIC SURGERY. 



size of a twenty-five cent piece covered with felt, is sometimes added 
to protect the outer malleolus from pressure. At the top of the 
upright where it presses on the outside of the thigh, a thin steel 
round pad should be added to distribute pressure. At the posterior 
extremity of the arm, at the top of the splint, 
is a strap which passes round the waist and 
buckles at the bend on the top of the upright. 
Double buckles riveted to the upright at suit- 
able places attach the straps from the leather 
pad which exerts pressure over the inner side 
of the knee. This pad should extend from the 
middle of the calf to the middle of the thigh 
and be wide enough to half encircle the limb. 
On its borders are leather straps, four or five 
on a side to buckle to splint. The efficiency 
may be much improved by riveting to the 
upright a short posterior calf band and a sim- 
ilar thigh band and connecting them with a flat 
steel rod. This affords, with leather straps, 
fixation for the knee like a ham splint and pre- 
vents bending that joint; these bands should be 
only one-third as long as the circumference of 
the limb. 
The measurement and weight of material are 
for a child three or four years old. After that age it is useless to 
try to correct knock-knee by irons. 




Fig. i 88.— Knock 
knee iron applied. 



BOW-LEG IRONS. 

Bow-leg irons likewise consist of an upright and a foot piece. 
They are used for lateral bowings. Here the upright runs on the 
inner instead of the outer side of the leg, from the inner malleolus 
to just below the perineum, where it curves forward and outward 
to form a long anterior arm. The anterior arm is convex forward 
to fit the curve of the upper thigh, ending at the trochanter. Half 
inch steel, No. 15 gauge, is sufficiently strong for the upright. It is 
slightly widened and is jointed below to a foot piece like the one 



BOW-LEG IRONS. 



379 



for knock-knee, excepting that the joint comes on the inner side 
of the foot where a broad pad covered with felt and leather prevents 
chafing. Three or four pairs of buckles, facing opposite ways, 
are riveted to the upright opposite the place of lateral bowing. On 
the outer side of the leg is a pad with straps like the one used for 
knock-knee. The curved anterior arm is covered with leather and 
is protected by a circular pad, to distribute pressure on the thigh 
at the angle where it begins. Two straps from this point encircle 
the thigh, one coming around and buckling into its 
own starting point, the other buckling to the outer 
end of the arm. The arrangement of these straps is 
modified when a pair of irons is used. 

As the internal malleolus is so prominent the ver- 
tical part of the base piece should have an offset of f 
of an inch. 

DANE BOW-LEG IRON: ANTERO-POSTERIOR 
BOW-LEG BRACE. 

This splint aims to prevent bending of the knee 
and consequent loosening of the corrective straps. 
The uprights are made of sheet steel, No. 16 gauge, f 
of an inch wide; the anterior one extends from a point 
an inch above the bend of the ankle to the middle of 
the thigh or higher, the posterior one from corre- 
sponding points on the back of the leg. They are 
fastened above to a thigh band of flat steel, an inch 
wide, covering the inner half of the thigh, and at the 
bottom to an ankle band of irregular shape cut out of sheet steel from 
a pattern, which serves to connect the lower ends of the uprights with 
the ankle-joint. This shape is seen in the accompanying drawing. It 
should clear the foot at all points, but, as under pressure of the lac- 
ings the foot may bend over to it, it is padded with leather and felt. 
It is perforated with a quarter inch hole for the spindle of the ankle- 
joint. 

The foot piece is similar to that already described. Two flaps 
of leather one on each upright are riveted to the surface nearest the 



Fig. 189.— 

Dane's brace 

for bow-leg. 



380 ORTHOPEDIC SURGERY. 

skin, from the bottom to the knee or above it if the knee bows 
out. They are cut wide enough to overlap each other slightly 
around the outer side of the leg and finished with a row of eye- 
lets or lacing hooklets which must be far enough apart to make 
it impossible to approximate them by tight lacing. The thigh band 
is protected with felt or leather and a strap and buckle secures it 
in place. 

SPLINTS FOR INFANTILE PARALYSIS. 

The Caliper Splint. — This has already been spoken of on page 
375. It has been found that toe-drop or paralytic calcaneus may be 
relieved by the modified use of this splint. By turning up from the 
edge of the steel tubing as it emerges from the boot heel, a small 
piece to strike against the upright of the splint, behind it or in 
front, further ankle motion is prevented, if it is made to strike behind 
the upright it prevents toe-drop — if in front, it prevents toe-raising. 
When there is only a paralytic toe-drop or a talipes calcaneus the 
uprights may end in a calf band and knee action be unrestrained. 

Apparatus for Infantile Paralysis. — To make paralytics walk, 
it is often necessary that the brace should have a rigid 
foot piece, and it is more convenient if the knee can be flexed 
in sitting. Infantile apparatus, therefore, should consist of a foot 
piece, two uprights, posterior bands, when necessary a knee-joint, 
and for some the outer upright has to extend above the hip with a 
joint above the trochanter and a broad leather belt, or the splints 
may be attached to a leather jacket. The form of foot piece 
varies with the distortion and a club-foot shoe or a varus shoe 
should be attached to the upright on the proper side of the 
foot. If no distortion of the foot be present, both uprights should be 
jointed at the ankle but the foot piece in other respects resembles 
that of an ankle splint. The external upright should reach from 
the malleolus to a point over the trochanter. 

The splint should be of steel, at least f of an inch wide and T V °f an 
inch thick, curved to follow the outline of the leg, leaving free space 
enough so that the outer malleolus and the outer surface of the knee- 
joint cannot touch it, but the rest of the leg may touch it. The inner 



SPLINTS FOR INFANTILE PARALYSIS. 381 

upright, made in the same way, reaches from the inner malleolus to 
an inch below the perineum. Both uprights should be jointed at the 
knee — the joints moving in parallel planes. The outer joint should 
be furnished with a drop catch or a spring catch, so that it can be 
loosened when the patient sits. The thigh band should be 3 inches 
wide on the top at its outer end, and if inches at its inner. It fits 
the back of the thigh, is riveted to the top of the uprights, and it 
is made of No. 15 gauge steel. The other connecting bands 
should be 1 J inches wide, of the same material, and should encircle 
the lower third of the thigh and the upper third of the calf. A 
knee cap and broad leathers with lacings cover the limb except 
at the knee, from the top of the splint to a point 2 inches above the 
malleoli. 

The illustration shows the drop catch and a self-locking spring 
catch. These catches are always applied to the knee-joint on the 
external upright because it is easier to adjust it there. Lacing 
hooklets placed at J inch intervals are convenient fastenngs. 

The foot piece we said varied to suit deformity. If the form of 
foot piece indicated to maintain a correct walking position demands 
one instead of two uprights, one may be cut off at the lower border 
of the calf band, or to make it more solid it may be bent at a right 
angle on the flat and itself extended as a posterior calf band and 
attached to the other upright by rivets. The finish of these splints 
should be nickel or bluing. 

No definite rules for infantile splints can be made, the splint must 
fit the condition and there are many different conditions in paralytics. 
The studentof orthopedics must design a splint for the indications pre- 
sented; sometimes paralysis is extensive and a double apparatus is 
indicated like the one described, only it has to be attached to a jacket 
by jointed hip pieces; sometimes a simple caliper with a stop piece 
to prevent toe-drop is all one needs, or even a short caliper and stop. 

Less extensive forms of infantile paralysis, where the knee action 
is normal, may require the support of one of the many forms of 
talipes apparatus as the club-foot shoe for equino-varus deformity, 
the valgus steel shoe, the steel shoe for simple equinus and for 
simple calcaneus. 



382 ORTHOPEDIC SURGERY. 

THE VALGUS SHOE. 

This apparatus is the reverse of that for equino-varus. It con- 
sists of a sole plate, an angle iron, an upright and a calf band. 

The sole plate is cut like a stiff paper or leather-board pattern 
made from the patient by the orthopedist; it is made of No. 16 
gauge sheet steel. A long flange is turned up at a right angle to fol- 
low the outer border of foot; the inner side of sole is raised up to 
lift the arch of the foot as much as is indicated on the pattern. 
The sole plate extends from the cleft under the toes to a finger's 
breadth in front of the tip of the heel, and the side flange from the 
head of the fifth metatarsal to a finger's breadth in front of the rear 
end of os calcis. It is bored with suitable holes for rivets to attach 
the angle piece, the leather lining, straps and buckles. 

The angle piece is of machine steel, No. 9 or 10 gauge, j of an 
inch wide, bent at a right angle; the sole part is riveted to the plate 
and ends at its inner border conforming to its shape; the vertical 
part has an offset to keep it away from the outer malleolus and a 
quarter-inch hole for the spindle of the ankle-joint. 

The upright, § of an inch wide and J inch thick, is broadened at 
the bottom, bored with J inch hole for the spindle of the ankle-joint 
(the distance from the sole to the center of the internal malleolus 
determines the height at which this should be placed); the upright 
ends 2 inches below the head of the fibula where it is riveted to a 
calf band. 

The cal] band is of No. 17 sheet steel, i\ inches wide and long 
enough to encircle the posterior half of the leg; it is riveted to the 
inner surface of the upright so that it projects \ inch in front of 
it. It is leather lined and has a wide strap and buckle. To the inner 
edge of the sole plate is there riveted, below the internal malleo- 
lus, a T strap of jacket leather cut by a separate paper pattern ; 
the top of the T should be an inch above the tip of the malleolus; 
the horizontal arms must be high enough to avoid pressing on the 
tendons at the annular ligament; one arm ends in a buckle, the 
other straps into and should be of such length that the buckle will 
lie on the upright so as not to press on the skin. 



SHOES FOR TALIPES EQUINTJS. 383 

Webbing straps, one from the hind end of the flange, and one from 
the inner border of the sole plate behind the head of the first metatar- 
sal, are made to fasten in the buckles on the flange. 

SHOE FOR TALIPES EQUINUS. 

This apparatus is like the one for fixation of the ankle-joint 
except that the uprights are stop-jointed at the ankle. The sole 
plate is sometimes riveted to the sole of the shoe, oftener the appara- 
tus is removable and worn outside the stocking. In order to prevent 
plantar flexion stop joints are used, but as at first it may not be 
possible to stop it entirely the pin should be placed slightly in front 
of where it should go — after stretching the foot by the use of this 
apparatus for one or two months, it may be reset in its 
proper place. The top of the uprights end in a posterior half band, 
of 17 gauge sheet steel, extending half way round the calf of the leg. 
If talipes equinus exists with varus, the shoe, see p. 384, is applicable; 
when it is a simple equinus a double upright apparatus is indicated; 
and when, in rare cases, valgus is present with equinus, the valgus 
shoe should be used with a stop in the ankle-joint. 

APPARATUS FOR TALIPES CALCANEUS. 

Talipes calcaneus may be treated by apparatus similar to that 
just described for equinus, but with the stop reversed so as to pre- 
vent toe-raising instead of toe-drop. 

THE CLUB-FOOT SHOE. 

This splint is a modification of the Taylor club-foot shoe. It 
consists of a sole plate, a base piece, an upright, and a calf band. 

The sole plate is cut from a piece of sheet steel, No. 16 or 18 
gauge, which is shaped from a pattern of stiff paper or card- 
board marked and cut by the orthopedist to fit the weight-bearing 
part of the foot, with two flanges turned up on the side to furnish 
pressure on the inner side of os calcis, and on the head of first meta- 
tarsal and great toe, the intervening portion between the flanges being 
cut away for lightness. The sole plate extends from J inch in front 



384 



ORTHOPEDIC SURGERY. 



of the posterior border of the heel to the cleft or the tips of toes. 
The forward side flange should extend from the proximal end of 
the head of the first metatarsal to the interphalangeal joint of the 
great toe; the posterior side flange presses on the side of the os 
calcis below and behind the internal malleolus, rising to cover the 
posterior superior corner of os calcis. The plate in front is the 
width of the ball of the foot compressed, and behind it is almost 




Fig. 190. — Inner and outside aspects of right foot wearing club-foot shoe. 



as narrow as the width of the os calcis. The pattern should be made 
and fitted to the foot with care, it is cut out of cardboard or 
leather-board with flanges properly turned up. 

A base or angle piece connects the foot plate with the upright at 
the ankle-joint. The angle divides it into two parts at right angles 
to each other; it is of steel of No. 10 or 12 gauge, and J of an inch 
wide, the posterior part is forged to fit the sole plate to which it is 
fastened by three steel rivets. The side portion at right angles to 
the sole plate rises a half inch above the internal malleolus with an 



THE CLUB-FOOT SHOE. 



385 



offsetting bend to give plenty of room so that the malleolus 
cannot possibly touch it; J inch below the top it is perforated in 
the center by a quarter inch hole for the spindle of the ankle-joint. 

The upright is a flat steel bar J to | of an inch wide and T ^- of an 
inch thick flattened at the lower end 
where it is perforated by the spindle of 
the ankle-joint; it ends at a point below 
the insertion of the inner hamstrings where 
it bears a small plate of metal covered with 
leather and a calf strap. In order to pre- 
vent toe-drop the widened end of this up- 
right is filed into the shape shown in the 
adjoining figure, and a pin or stop is 
fastened in the base piece. 

The sole plate is covered with thin calf- 
skin, strong webbing straps secure the foot 
to it, which exert pressure on the outer side 
of the foot over the calcaneo-cuboid joint, 
and hold the external malleolus firmly to 
the inner side of the base piece. Various 
schemes are used to obtain strap pressure 
at different points of the foot. One 
method is to attach to the outer side of 
the sole plate, opposite the calcis, a tri- 
angular bit of leather on which a small 
metal ring is secured by stitching. A 
strap from the upper corner of the angle 
or base piece passes behind the tendo- 
Achillis, over the external malleolus, 
through the metal ring; then turns inward 
over the top of the foot and is attached 
to a buckle near the ankle-joint. The front of the foot is secured 
by a single strap riveted to the sole plate which passes behind the 
head of the fifth metatarsal, inward and forward, fastens in a small 
buckle on the inner side of the front flange. 

The Club-foot Shoe for Talipes Varus.— For the correction of 
2 5 




Fig. 191. — Club-foot shoes 
prolonged to waist. 



386 ORTHOPEDIC SURGERY. 

talipes varus, especially in babies, it is necessary in order to make 
them toe-out, to prolong the upright, carrying it across in front of 
the shin to the outer side of the leg, thence straight upward to a knee- 
joint, upward again to the trochanter, where a metal band is attached 
to a tee piece by a movable joint at the hip and belted around the 
waist. This merely serves to make them toe-out. 

FLAT-FOOT PLATES. 

These are made of many different patterns by different orthopedic 
surgeons and as they are used to accomplish different objects, the 
shape is varied for different patients. The surgeon knows what 
he is to accomplish and uses his good mechanical judgment. The 
best guide is to have the patient stand on a low table while the 
surgeon tries with his hand to learn in what way the applied force 
corrects best; the thrust upward or sideways of the plate is thus 
determined. Upward pressure may be made under the front of the 
os calcis and the sustentaculum tali; under the scaphoid and cunei- 
forms; or behind the heads of the second and third metatarsals; side- 
ways thrust is obtained by raising the inner edge of the plate, which 
is made to slope to the outer side; any steep slope makes the foot slide 
which can be prevented by turning up one or two flanges on 
the outer border, or a high inside border and an outer flange at the 
heel may hold the os calcis while the front of the foot receives a 
side thrust from the sloping of the plate. Abduction of the 
front of the foot often demands two outer flanges, one opposite the 
os calcis and the other against the shaft of the fifth metatarsal and 
an inner border extending high over the scaphoid, for if the edge 
should be close to the tubercle of the scaphoid it will hurt. Ordi- 
narily the entire width of the sole is to be supported. The front 
of the plate should end behind the sesamoid bones of the great toe 
and the posterior edge cover the weight-bearing part of the heel. 
For flexible feet a shorter plate is used — for rigid ones a longer one. 

Steel plates should be tried on and fitted with wrenches before 
tempering; and it is a good plan if in doubt to have them worn for 
a day so that the places which hurt may develop. 

Among many defects which may be present in flat foot plates they 



FLAT-FOOT PLATES. 387 

should not, at the outer border, overhang the shank of the boot; 
nor rock, that is both the front and back edges should be every- 
where in contact with the sole; when applied to the relaxed foot the 
edges should not spring off from it. When the patient stands on the 
plate he should not feel a sharp hump or ridge, but he should feel 
an even, well -distributed pressure; the edges should not press in 
or hurt. If there are painful points on the foot, the plate should be 
depressed or fashioned to avoid them, and there is much to think of, 
both when carving the cast and when the plate is tried on; — a 
little experience is the best teacher. 

When the cast is prepared it is marked by the surgeon with the 
outline of the proposed plate. A paper pattern is cut from this 
and used to transfer the outline of the plate to the sheet steel. 
This should be of Nos. 16 to 19 gauge according to the patient's 
weight. It is heated to bright cherry red and shaped to the 
carved plaster cast by the blacksmith; rough shaping and turning 
up flanges is done on the anvil — finer work on the cast or on a lead 
anvil. The rough edges are filed off or ground and the plate is ready 
to try on. Afterward it is tempered and nickel plated or blued. It is 
sometimes covered with leather, thin sheep-skin, or dog skin. When 
a plate tends to slip in the boot, a thin leather insole cut like the 
insole of the boot may be fastened to its lower surface. 



INDEX 



Abscess in acute arthritis, 174, 195 

ankle disease, 260 

actinomycosis, 173, 189 

dactylitis syphilitic, 175 

elbow disease, 265 

from operation to reduce hip, 57 

hip disease, 232, 245 

in infant's joints, 65 

lumbar, 213 

mediastinal, 213 225, 

osteomyelitis or periostitis, 173, 
188, 190, 195, 197, 199 

Pott's disease, 209, 212, 225 

psoas, 213 

retropharyngeal, 226 

sacro-iliac disease, 226 

shoulder disease, 264 

syphilitic arthritis, 174, 203 

tumor albus, 253, 256 

typhoid fever joints, 197, 201 
Absence of clavicle, 21 

extremities, 1, 3 

femur, 7 

fibula, 8 

legs or arms, 2 

patella, 7, 8 

radius, 4 

ulna, 4 
Acetabulum in congenital luxations, 

42 
Achondroplasia, 66 

fractures in, 69 
Acromegaly, 177, 288 
Actinomycosis, 173, 189 
Acute arthritis, 174 

atrophic spinal paralysis, 303 

synovitis, 189 
Adult's congenital hip luxation, 48 
Amniotic bands, 2 
Amputations, intrauterine, 2 

for deformed foot, 10 

hip disease, 246 



Angular spinal curvature, 207 
Ankle arthrodesis for paralysis, 314 

fixation splint, 376 
Ankle-joint disease, tuberculous, 260, 
263 
abscess, 260 
Bier's treatment, 268 
diagnosis, 261 
excision, ankle, 262 
excision, tarsal bone, 262 
pathology, 261 
symptoms, 261 
treatment, 262 
Ankylosis from congenital syphilis, 65 
Anomalies of the extremities, 1, 12 . 

trunk, 12, 25 
Anomalies of the spine, 12, 18 
adas, 14 
pelvis, 3, 18 
ribs, 12, 15, 19 
Anterior bow-legs, 279 
poliomyelitis, 303 
Antero-posterior curvature, 207 
Aorta distorted in scoliosis, 94 
Apparatus for calcaneus, 383 
bow-leg, 378, 379 
club-foot, 383, 385 
hip disease, 364, 372 
fixation of ankle, 376 
knock-knee, 377 
lateral curvature, 362 
paralysis, 380, 386 
Pott's disease, 350, 362 
valgus, 382, 383 
varus, 385 
Aran-Duchenne, progressive atrophy 

of, 71 
Arteriosclerosis in ostitis deformans, 

287 
Arthrectomy of tumor albus, 256 
Arthritis, acute, 174 

deformans, 177, 290 



389 



39° 



INDEX. 



Arthritis, deformans, atrophic, 291 
hypertrophic, 292 
in children, 293 
treatment, 291, 294 
dry, 291 

hemophylica tardiva, 186 
in infancy, 197 
gonorrhoea, 200 
pneumonia, 199 
sepsis, 195 
typhoid fever, 198 
infectious or septic, 195 
osteo-arthritis, 290 
rheumatoid, 290 
sicca, 290 
subacute, 174 
syphilitic, chronic, 174 
tuberculous, 174 
villous, 183, 201, 290 
Arthrodesis for paralysis, 314 
Arthropathy, tabetic, 289 
fractures in, 69 
Articular processes in scoliosis, 92 
Artificial hands, 3 
Astragalus, osteotomy of, 35 
Asymmetrical skulls, 86 
Athanassow on congenital scoliosis, 18 
Atrophic arthritis deformans, 290 
Atrophy of bone, senile, 69 
Atrophy, progressive muscular, 71 
Erb's juvenile, 73 
pathology, 72 
Avulsion of tibial tubercle, 180 

Back braces, 350, 362 
Taylor's, 351 
quadrilateral, 358 
with movable shoulder piece, 

360 
spring steel, 361 
Back, hollow, hollow-round, 140 

round, 140 
Back knee, 152 
Bandy legs or bow-legs, 273 
Bed frame for Pott's disease, 219 

plaster bed, Pott's disease, 221, 

33 6 
Bier's method of venous stasis, 267 
Bleeder's joint, 185 
Bone cysts, fractures with, 69 

diseases, 171 

filling of Moorhof, 255 

inflammations, 173 

necrosis, 173 



Bone, nutritive disorders, 175 

operations for club-foot, 35 

trauma and repair, 171 

tuberculosis of, 174 

tumors producing fractures, 69 

syphilis, 174 
Bowing of the femur, rhachitic, 275 

not rhachitic, 150 
Bow-legs, anterior, 279 

braces, 378, 379 

deformity of tibia, fibula, 275 
not rhachitic, 151 

osteoclasis, 277 

osteotomy, 278 

rhachitic, 273, 279 

treatment, 276, 279 
Bradford's bed frame, 219 

reduction congenital luxations, 
54, 69 
Braces for bow-legs, 378, 379 

lateral curvature, 362 

malformed thorax, 19 

knock-knee, 377 

torticollis, 356 

Pott's disease, 223, 350, 362 
Brackett's frame for plaster jackets, 

338 
Brittle bones, 67 
Bunion toe, 165 
Bursitis near the hip, 236 

Caliper splint, 375 
Callouses of club-foot, 26 
Cardiac enlargement in scoliosis, 94 
Caries of the spine, 207, 225 

abscesses, 205, 209, 211 

ambulatory, 223 

braces, 223, 224, 350, 362 

complications, 224 

diagnosis, 214 

laminectomy, 224 

lateral deviation, 215 

local treatment, 219 

paralysis, 214, 224 

pathology, 208 

physical signs of, 210 

prognosis, 217 

symptoms, 210 

treatment, 217, 225,226 

plaster jackets, 224 
Cartilages displaced in knee, 181 
Causes of lateral curvature, 104 
Celluloid jackets, 341 
Cerebral paralysis or palsy, 74 



INDEX. 



39 1 



Cervical ribs, 14, 16, 18 
Cervico-dorsal scoliosis, 101 
Charcot's disease, 177, 289 
Chest, funnel-chest, 144 
Chondrodystrophia foetalis, 66 
Chronic arthritis or arthritis defor- 
mans, 290 
diseases of bones, 203 
dry synovitis, 290 
gout, 295 
osteomyelitis, 192 
rheumatic gout, 290 
rheumatism, 290 
Club-foot, acquired, 69, 72, 74, 303 
congenital, 25, 37 

age for correcting, 29 

callouses, 26 

cause, 25 

choice of method, 27 

combined operations, 37 

correction of, 27, 343 

cuboid dropping, 36 

deformities, 25 

degrees of, 26 

diagnosis, 25 

disability of, 26 

dividing ligaments, 29 

equino-varus, 25 

fasciotomy, 29 

forcible correction, 32 

frequency, 25 

gait, 26 

infantile, 27, 342 

mechanical appliances, 32, 

383 

operations, 29, 34, 35 

painful, 26 

Phelps' operation, 34 

plaster bandage, 27, 342 

protecting plaster, 27 

prognosis, 27 

relapses, 27 

treatment, 28 

splints for, 27 

tin splints, 28 

Wolff's method, 34 

wrenches, ^^ 
from spina bifida, 69 
Club-hand, 3, 5 

from spina bifida, 69 
treatment, 5, 7 
varieties, 4, 5 
Collars for cervical caries, 357, 358 
Complicated dorsal scoliosis, 102 



Congenital amputations, 2 
defects of arm, 2, 3 

clavicle, 21 

femur, 7 

fibula, 8 

foot, 10 

patella, 7 

radius, 3, 6 

spine, 12, 18 

tibia, 9 
deficiencies, see defects 
deformities, clavicle, 21 

fibula, 8 

knee, 60, 61 

pelvis, 18 

scapula, 22, 24 

shoulder, 21, 24, 63 

spine, 12, 18 

thorax, 18 

tibia, 9 

trunk, 12, 24 
dislocations and subluxations, 255 

64 
dislocation of ankle, 8, 9 

elbow, 63 

hip, 38, 68 

Bartlett machine, 49 . 
Bradford's machine, 53 
bloody reduction, 55 
anterior, transposition, 

57 
methods reducing, 58 
displacements, 40 
depth socket, 43 
diagnosis, 45 
double, 41, 44 
exercises, 48 
frog position, 51 
gait, 44 

Hoffa's method, 49 
in adult, 48 
in infancy, 43 
Lorenz' method, 49 
manual reduction, 48 
mobility, 44 
muscles in, 41 
Mueller's position, 53 
neck of femur, 42 
Nelaton's line, 44 
palliation of, 47 
pathology, 40, 42 
pelvic inclination, 41 
perineum, 44 
plaster bandage, 55 



392 



INDEX. 



Congenital dislocation of hip, re- 
cumbency, 48 
secondary socket, 43 
Schede's method, 49 
symptoms, 43 
tenotomy, 45 
treatment, 47 
Trendelenberg's test, 44 
X-ray diagnosis, 47, 52 
waddling in, 43 
knee, 60 
patella, 62 
shoulder, 62 
wrist, 64 
displacement of hand, 4, 6 
elevation of scapula, 21 
double, 22 
treatment, 22, 23 
hypertrophy, unilateral, 11 

of a limb, 11 
lateral curvature, 12, 16, 104 
luxations, 24, 64 
hip, 38, 58 
ankle, 8, 9 
elbow, 63 
knee, 60 
patella, 62 
shoulder, 62 
wrist, 64 
subluxations, 24, 37, 60, 62 
hip, 60 
knee, 61 
tarsus, 24 
rickets, 65 

osteogenesis imperfecta, 66 
syphilis, 65 
tuberculosis, 65 
Contracted foot, 153 

muscles in elevated scapula, 23 
Convalescent hip splint, 367, 369 
Corsets, spinal (see braces and jackets), 

34i 
Correction of club-foot under ether, 

32 
Cranial irregularity or asymmetry, 85 
Coxa valga, 149 

vara, 7, 145, 273 
traumatic, 147 
Coxitis, 230, 249 

Dactylitis syphilitic, 174, 204 
Dane's brace for Pott's disease, 358 
bow-leg, 379 
hip splint, 369 j 



Defects, congenital, 1, 81 
of limbs, total, 1 

partial, 3 
long bones, 3, 9 
clavicle, 21 
ribs, 18 
Deforming ostitis, Paget's disease, 287 
Deformities, congenital, 1, 81 
Deformity, absence of clavicle, 21 
long bones, 3, 9 
lateral curvature, 217 
Friedreich's disease, 71 
flat-foot, 158 
Pott's disease, 215 
progressive muscular atrophy, 

72, 73 
Disability, congenital hip luxation, 

39 
Diseases of bones, summary, 171, 
179 
joints, 171, 179 
nutrition, 270 

tuberculosis of ankle, 260, 263 
elbow, 265, 267 
hip, 230, 249 
knee, 250, 260 
sacro-iliac, 226 
spine, 207, 229 
shoulder, 263 
wrist, 267 
Dislocation, congenital, of ankle, 8, 9, 
62 
elbow, 63 
knee, 61 
hip, 38, 58 
patella, 62 
shoulder, 62 
spina bifida, 69 
wrist, 5, 64 
of semilunar cartilage, 181 
Displacement of hand, congenital, 4 
Distortion of aorta in scoliosis, 94 
Distortions from spina bifida, 69 
Distribution of paralysis (spastic), 75 
Dorsal scoliosis, 100 
Drehmann's cervical ribs, 18 
Dry arthritis, 290 
Dystrophies, the, 71, 81 

Aran-Duchenne type, 71 

Erb's type, 73 

Landouzy Dejerine type, 73 

leg type, 72 

peroneal, 72 

pseudo-muscular hypertrophy, 73 



INDEX. 



393 



Ectromelian deformity, i 
Elbow, congenital dislocation, 63 
Elbow-joint disease, tuberculous, 265, 
267 
Bier's treatment, 268 
excision for, 265 
Elevation of scapula, congenital, 21, 23 
Empyema, a cause of scoliosis, 105 
Enlargement, cardiac, in scoliotics, 94 
Epidemics of infantile paralysis, 304 
Epiphyseolysis for knock-knee, 283 
Epiphysis, separation of, in syphilis, 65 
Essential paralysis of childhood, 303 
Erb's juvenile atrophy, 73 
Excavating an acetabulum, 59 
Excision of knee for tumor albus, 266 
Exercises for elevated scapula, 22 
round shoulders, see scoliosis 
scoliosis, 116 
spastic paralysis, 76 
thoracic malformation, 20 
Exostoses of the foot, 164 
Extra bone in elevated scapula, 21, 23 
digits or limbs, 10 
tarsal and wrist bones, 10 

Face-shoulder type of dystrophy, 73 
Fasciotomy for club-foot, 29 
Femoral head in congenital luxation 
hip, 42 

neck in congenital luxation hip, 42 
Femur, malformations of, 7 
Fixation splint for ankle, 376 
Flat-foot, 156, 163 

casts for, 347 

deformity, 158 

paralytic, 162 

plates, 386 

rigid, 161 

rhachitic, 283 

treatment, 159 
Foot, exostoses of, 164 

tuberculosis of, 260, 263 
venous stasis for, 268 
Forcible stretching for spastic paral- 
ysis, 76 
Forward shoulders, 141 
Fractures in osteomalacia, 69, 285 

osteogenesis imperfecta, 66, 69 

osteoporosis, 69 

rickets, 284 
Fragillitas ossium, 67, 176 
Frames for applying jackets, 334, 338 

recumbency, 219 



Friedreich's disease, 70 
pathology, 71 
Functional joint disease, 178, 297 
Funnel-chest, 144 
Fusion atlas and skull, 14 

bones of elbow, 64 

bones from syphilis, 64 

vertebrae, 15 

ribs, 15, 16, 20 

Gant's osteotomy (subtrochanteric), 

244 
Gas pipe splint for the hip, 373 
Genu introrsum knock-knee, 279, 283 

recurvatum, 60, 152 

valgum, 279, 283 

varum, 273 
Genuclast, 259 

Gliosis of the cord, Friedreich's, 71 
Goldthwait's frame for jackets, 337 

head support, 355 
Gonorrhceal arthritis, 200 

rheumatism, 200 
Gout, 178, 294 
Gumma of bone, 174 

Hair on back (spina bifida), 69 
Hallux rigidus, 167 
valgus, 165 
varus, 167 
Hammer toe, 167 
Hammock for plaster jacket, 334 
Handless cripples, 3 
Head supports, 353, 357 
Heart enlarged in scoliosis, 94 
Hemophilia, 185 
Hemimelian deformity, 1, 2 
Hereditary ataxia, 70 
Hernia in spina bifida, 69 
Hip, congenital dislocation of, 38, 58 

subluxation, 60 
Hip disease, 230, 249 

atrophy, 231, 234 

abscess, 232, 245 

acetabular, 232 

advanced, 233 

ambulatory treatment, 242 

amputations for, 249 

abortive treatment, 246 

clinical history, 233 

diagnosis, 237 

duration, 243 

double, 245 

excision of hip, 247 



394 



INDEX. 



Hip disease, gait, 233 

muscular spasm, 234 

malposition, 236 

night cries, 234 

osteotomy, 244 

pain, 233 

prognosis, 239 

recumbency, 241 

restriction of movement, 236 

shortening, 236 

splints, 243, 364, 373 

traction, 241 

treatment, 240, 249 
Hochstand des schulterblattes, 21, 24 
Hoffa's reduction congenital hip luxa- 
tion, 55 
Hollow foot, 3, 15 
Hollow round back, 140 
Hump foot, 153, 164 

back, Pott's disease, 209, 230 
Hypertrophic arthritis deformans, 290 
osteoarthropathy, secondary, 176, 
288 
Hypertrophy, congenital, 11 

pseudo-muscular, 73 
Hysterical joints, 297 

Inclination of pelvis in hip luxation, 

4i 
Incoordination in spastic paralysis, 74 

hereditary ataxia, 71 
Infant's club-foot, 26, 28 
arthritis, acute, 197 
Infantile paralysis, 303 

deformities, 307 

dislocations, 309 

arthrodesis for, 314 

electric tests for, 309 

epidemics, 304 

operations for, 313 

scoliosis, 308 

sequelae, 308 

symptoms, 305 

tendon transference, 315 

splints for, 380, 385 

treatment, 310 
Infantile spinal palsy, 303 

syphilis, 203 
Inflammations, bones and joints, 173 
In-knee or knock-knee, 279, 283 
Irregular skulls, 85 
Irons for knock-knees, 377 

bow-legs, 378, 379 
Ischias scoliotica, 108 



Jackets for malformed thorax, 20 
round shoulders, 342 
Pott's disease, 224, 334, 340 
scoliosis, 339, 341 
celluloid, 341 
leather, 340, 363 
plaster-of-Paris, ^33, 34© 
removable, 340, 341, 363 
Joint and bone disease (summary), 

171, 179 
Joint disease of Charcot, 289 
inherited syphilis, 654 
of bleeders, 185 
tuberculous, 174, 267 
nutritional, 175 
Joints, inflammations of, 174 

trauma and repair in, 172 
Juvenile atrophy of Erb, 73 
osteomalacia, 286 

Knee, back knee, 60 

lax knee of absent patella, 8 

snapping knee, 61 
Knee splints, Thomas', 373, 376 

tuberculosis, 250, 260 
Knee-jerks in Friedreich's disease, 71 

Pott's disease, 214, 224 
Knock-knee, 279, 283 

epiphyseolysis, 282 

osteokampsis, 283 

osteotomy, 281 

causes of, 279 

tibial twist in knock-knee, 280 

treatment, 281 
Kyphos or kyphosis of Pott's disease, 

210 
Kyphosis, congenital, 18 
Kyphoscoliosis, 89, 100 
Kyphotome of Taylor, 339 

Laminae vertebral deformed in scolio- 
sis, 93 
Laminectomy, 224 
Landouzy Dejerine type of dystrophy, 

72 
Lateral curvature of spine, 13, 18, 87, 
138 
congenital, 14, 16, 104 
braces, 362, 364 
causes of, 104 
cervico-dorsal, 10 1 
changes, spinal column, 90 
bodies, vertebral, 90 
foramina, 91 



INDEX. 



395 



Lateral curvature of spine, changes, 

muscles, 94 

ribs, 93 

shoulder girdle, 93 

sacrum, 94 

thorax, 93 

viscera, 94, 96 
clinical grades of, 111 
complicated dorsal, 102 
corrective jackets, 134 
creeping exercises, 128 
curves of deformity, 88 

physiological, 89 
curves, total, 97 

dorsal, 100. 

lumbar, 98, 99 

lumbo-dorsal, 98 
deformities, 96 

cervico-dorsal, 101 

dorsal, 100 

lumbar, 98 

lumbo-dorsal, 98 

rotation, 88 

torsion, 88 

rhachitic, 105, 283 
dorsal, 100 
empyema, 105 
examination of patient, 109 
exercises, 116, 129 
frequency, relative, 96 
from empyema, 105 

Friedreich's disease, 71 

functional cause, 108 

osteomalacia, 285 

rickets, 105, 283 

Sprengel's deformity, 22 
functional, 108 
Hoke's operation, 138 
inclination of spine, 88 
jackets for, 339, 363 
kyphoscoliosis, 88 
lateral deviation in, 87 
lordoscoliosis, 89, 141 
lumbar and lumbo-dorsal, 98 
malpostures, 138 
measures for flexibility, 132 
mechanical, 105 
osteogenous, 105 
pathology, 89, 96 
physiological curves, 89 
postural deformities, 87, 138 
plaster jackets, 339, 363 
photographs, no 
records, no 



Lateral curvature of spine, rickets, 
105, 283 
rotation in, 88 
structural, treatment, 132 
test of flexibility, in 
torsion, 88 
tracing devices, no 
treatment, 113, 139 
Wullstein's treatment, 137, 

3 6 3 
Lateral deviation in Pott's disease, 215 
Leather jackets, ^3, 4°, 349 > 3 6 3 

splints, 349 
Little's disease, 74 
Locomotor ataxia, joints in, 289 
Lordoscoliotic curvature, 89, 141 
Lorenz' reduction congenital hip luxa- 
tion, 49 
Lovett's frame for jackets, 338 
Lumbar scoliosis, 98 
Lumbo-dorsal scoliosis, 98 
Lung disease in scoliosis, 94 
Luxation of hip, congenital, 38, 58 

ankle, 8, 9, 62 

elbow, 63 

knee, 60, 61 

shoulder, 62 

wrist, 64 

McE wen's osteotomy, 282 
Malformations, 1, 24 

amniotic bands causing, 1 

ectromelian, 1 

extremities, 1, n 

from supernumerary parts, 10 

hemimelian, 1 

foot, 9, 10 

limbs, 1 

pelvis, 18 

phocomelian, 1 

spina bifida, 69 

spine, 12, 18 

thorax, 18, 20 

supernumerary parts, 10 

shoulder girdle, 21, 24 
Malleotomy, 36 
Malpostures, spinal, 138 
Malum senile, 290 

Manipulative reductions of the hip, 49 
Marrow of bone, inflammation of, 

173- 191 
Mechanical scoliosis, 105 
Mediastinal abscess of Pott's disease, 

226 



39 6 



INDEX. 



Metatarsalgia, painful foot, 162 
Morbus coxae, 230, 249 
Morbus coxarius, 230, 249 
Movements, normal spinal, 112 
Muscle stretching for paralysis, 76 
Muscle transference, 77, 315 
Muscular dystrophies, 71, 81 
Myositis ossificans, 327 
Myotomy for spastic paralysis, 76 

Necrosis of bone, 173 
Neglected club-foot, 26 
Nerve grafting, 80, 320 
Neurasthenia, joint symptoms, 298 
Neuromimesis, 298 
Non-deforming club-foot, 153 
Non-development, see absence of 
Non-formation of a limb, 2 
Non-rhachitic bow-leg, 151 

knock-knee, 152 
Normal movements of spine, 112 
Nutritive disorders of bone, 175 

Oblique pelvis, 18 
Obstetrical paralysis, 78, 81 
elbow deformity, 79 
Jones' operation, 81 
natural cure of, 81 
nerve grafting, 80 
pathology, 78 
position of arm, 79 
shoulder dislocated in, 79 
types, 79 

tendon transplantation, 81 
(Edema of cord in paralysis of Pott's, 

209 
Operation for club-hand, 6 

congenital hip luxation, 55 
defect of tibia, 9 
elevation of scapula, 23 
infantile paralysis, 313 
hip abscess, 245 
excision, ankle, 262 
hip, 247 
knee, 255 
elbow, 266 
laminectomy, 224 
osteotomy, 6, 9, 35, 37, 244, 278, 

281 
nerve grafting, 80, 320 
tendon transference, 77, 81, 315 
tenodesis, 320 

tenotomy, 29, 30, 31, 79, 318 
Os calcis, osteotomy, 35 



Ossification, patella, 7 
Osteoarthropathy, secondary hyper- 
trophic, 288 
Osteoarthritis, 290 
Osteochondritis, 65, 203 
Osteoclasis for bow-leg, 277 
Osteoclast, 277 
Osteogenesis imperfecta, 69 
Osteokampsis, 283 
Osteomalacia, 176, 284 

fractures, 69, 285 

spine, 286 
Osteomyelitis, 173, 190, 195 

chronic, 192 

hip, 194 

of spine, 194 

treatment, 192 

typhoid fever, 195 
Osteophytes, foot, 164 

in syphilis, 205 
Osteoporosis, 69 
Osteotomy, bow-leg, 278 

club-hand, 6 

club-foot, 35, 37 

fibular defect, 9 

Gant's, 244 

knock-knee, 282 

McEwen's, 282 

subtrochanteric, 244 
Ostitis, chronic, of hip, 230 
Ostitis deformans, 177, 287 
Ostitis of spine, tuberculous, 207 
Out-knee or bow-leg, 273 
Oval ring head support, 353 

Paget's disease, ostitis deformans, 177, 

287 
Painful foot, metatarsalgia, 162 

exostoses, 164 
Painless fractures, osteogenesis, 66 
osteomalacia, 285 
rickets, 284 
Paralysis, infantile, 303, 320 
deformities, 307 
dislocations, 309 
epidemics, 304 
electric tests, 309 
nerve grafting, 320 
operations, 313 
scoliosis, 308 
sequelae, 308 
symptoms, 305 
tendon transference, 315 
Paralysis in Pott's disease, 209, 214 



INDEX. 



397 



Paralysis, obstetrical, 78, 81 
attitude, 78 
elbow luxation, 79 
natural cures, 81 
nerve grafting, 80 
operation, Jones', 81 
shoulder dislocation, 79 
tendon transference, 81 
three types of, 79 
Paralysis, spastic, 74, 78 

condition of muscles, 74 
idiocy, 74 
physical signs, 74 
treatment, 75 
tendon transferences, 76 
Tubby's operation, 77 
Paralytic deformities, 69, 74, 78, 303 
club-foot, 69, 74, 303 
flat-foot, 162, 313 
Passive hyperemia, Bier's treatment, 
267 
gonorrhceal arthritis, 202 
Patella, absence of, 7, 8 

dislocation, congenital, 62 
ossification of, 7 
rudimentary, 7, 8, 
Patellar tendon too long, 62 

misinserted, 8, 62 
Pelvis amesial, 18 

deformity of, 18, 94 
oblique, 18, 94 
Periarthritis, 201 
Periostitis, 173, 188 

chronic, 189 
Pes arcuatus, 8, 153 
cavus, 25, 153 
excavatus, 153 
planus, 25, 156, 283 
Phelps' operation for club-foot, 34 

shoulder luxation, 63 
Phocomelian deformity, 1, 2 
Plaster bandage, 330 
bed, 221, 336 
casts, 346 
for club-foot, 342 
jackets, 333, 340 
shell, 336 

spica bandage, 344, 345 
Plates for flat-foot, 386 
Pleurisy in scoliosis, 94 
Pneumonia, joints affected in, 199 
Pneumococcus joint infections, 199 
Poliomyelitis, anterior, 303 
Posterior curvature, spine, 207 



Pott's disease, 207, 225 

abscess,. 209, 211 
braces, 224, 350, 362 
ambulatory treatment, 233 
cause of paralysis, 209 
complications, 209, 224 
deformities, 215 
diagnosis, 214 
lateral deviation, 215 
laminectomy, 224 
paralysis, 209, 214, 224 
pathology, 208 
physical signs, 210 
recumbency, 219 
symptoms, 210 
treatment, general, 217 
local, 219 
of abscess, 225 
of paralysis, 224 

Progressive muscular atrophy, 71 
Erb's type, 73 
face-shoulder, 73 
peroneal or leg, 72 

Pseudo-muscular hypertrophy, 73 
deformity, 74 
recovery, 74 

Puerperal osteomalacia, 286 

Pulmonary tuberculosis, in Pott's, 217 
scoliosis, 94 

Quadriceps tendon long, 262 

misinserted, 8 
Quadrilateral back brace, 358 

Radius, defects of, 4, 6 
Recumbency in Pott's disease, 219 

hip disease, 241 
Reduction congenital hip dislocation, 

48,56 
Relapsed club-foot, 26, 27 
Resistant club-foot, 26 
Rhachitis, rickets, 272, 285 
Rheumatic fever, 197 

gout, 290 
Rheumatism, chronic, 290 
Rheumatoid arthritis, 290 
Ribs, defects of, 18 

cervical, 14, 16, 18 

absent, 19 

braces for defects of, 19 

angles of, 93 

bicipital, 19 

fusion of, 19 

joints in scoliosis, 93 



398 



INDEX. 



Ribs, hump in scoliosis, 93 
Rickets, rhachitis, 272, 284 

congenital, 65 

causing scoliosis, 105 

deformities, 273, 274, 279, 281, 
283 

treatment, 276, 281 
Rigid flat-foot, 161 
Rotation deformity of scoliosis, 88 

of thorax, 93 
Round shoulders, 139 

treatment, 143 
Round back, 140 
Round hollow back, 140 
treatment, 143 

Sacro-coxitis, sacro-iliac disease, 226 

Sacro-iliac disease, 226 

Sacrum, malformation of, 12, 13, 15, 18 

of scoliosis, 94 
Schede's method of reducing hips, 49 
Schueller's bacterium of arthritis de- 
formans, 290 
Schools for cripples, 2, 3 
Scoliosis, lateral curvature, 87, 139 
and congenital elevation scapula, 
22 
Friedreich's ataxia, 71 
phthisis, 94 
affecting shoulder girdle, 93 

thorax and ribs, 93 
and pleuritic disease, 94 

cardiac disease, 95 
braces, 362 
cervico-dorsal, 101 
causes of, 104 
complicated dorsal, 102 
congenital, 14, 16, 104 
corrective jackets, 134 
creeping exercises, 128 
curvature, total, 97 
curves, distribution of, 88 
dorsal, 100 
deformities, 96 
distortion of aorta, 95 

bodies of vertebras, 90 
arches, of vertebrae, 91 
foramina vertebrae, 91 
sacrum, 94 
spinal column, 90 
elevation, scapula, 22 
empyema causing, 105 
examination and record, 109 
exercises for, 116, 139 



Scoliosis, explanation of terms, 87 

frequency, 96 

Friedreich's ataxia, 71 

from empyema, 105 

from paralysis, 108 

from rickets or osteomalacia, 104, 
283 

functional, 108 

Hoke's operation, 138 

inclination of spine, 88 

jackets, leather, 339, 363 
plaster corrective, 134 
for support, 338 

kidneys, 95 

kyphoscoliosis, 88 

lateral deviation in, 87 

leather jacket, 339, 363 

lordo-scoliosis, 89 

liver in, 95 

lumbar, 98 

lumbo-dorsal, 98 

malpostures, 138 

measures to regain flexibility, 128 

mechanical, 105 

modified structure of spine, 90 

muscle changes, 94 

osteogenous, 105 

pathology, 89, 96 

photographs for record, no 

physiological curves, 89 

plaster jackets, 134, 338 

position of diaphragm, 95 

postural deformity, 87, 138 

pneumonia, pleurisy, phthisis, 94 

rotation in, 88 

sacrum, 94 

spleen, 95 

test of flexibility, in 

three grades of, 112 

torsion in, 88 

tracings of spine, in 

total, 97 

treatment, 113 
Scorbutus, 270 
Scurvy, 270 
Secondary hvpertrophic osteoarthrop 

athy, 288 
Semilunar cartilage, dislocation of, 

181 
Sequestrum, 173 
Shoulder dislocation, 62, 79 
congenital, 62 
paralytic, 79 
Shoulder malformations, 21, 24 



INDEX. 



399 



Shoulder-joint disease, tuberculous, 
263 
excision, 264 

venous stasis treatment, 269 
Shoulders, forward, 141 
round, 139 
stooping, 139 
treatment, 143 
Simulated deformities, 297 
Shoe for correction club-foot, 383 

valgus, 382 
Skull, irregular growth, 85 
Socket of hip luxations, congenital, 43 
Spastic paralysis, 74 
Spica bandage, plaster, 344, 345 
Spina bifida, 69 
occulta, 69 
paralysis, 69 
Spinal arthritis, typhoid, 199 
Spinal caries, 207, 226 

ambulatory treatment, 223 
braces, 224, 350, 362 
abscess, 209, 211 
cause of paralysis, 209 
deformities, 215 
diagnosis, 214 
go-cart for, 218 
laminectomy, 224 
lateral deviation, 215 
paralysis, 209, 214, 215 
prognosis, 217 
pathology, 208 
signs, 210 
symptoms, 210 
treatment, 217, 227 
abscess, 225 
complications, 224 
general, 217 
local, 219 
laminectomy, 224 
Spinal curves, physiological, 89 
Spinal movements, 112 
Spinal syphilis, 207 
Spine, age and infancy affecting, 89 
caries of, 207, 227 
cervico-dorsal curvatures, 101 
changes in scoliosis, 90 
column, 90 

bodies of vertebrae, 90 
ribs and thorax, 94 
pelvis, 93 
complicated dorsal curvature, 102 
deformities, scoliotic, 96 
dorsal scoliosis, 100 



Spine, growth, normal curves, 89 

lordo-scoliosis, 89 

kyphoscoliosis, 88 

movements of, 112 

ossification, 89 

malformations, 12, 19, 104 

numerical variations, 12, 17 

osteomyelitis, 194 

syphilis, 207 

tuberculosis, 207 

rickets, 104, 283 

osteomalacia, 285 

typhoid fever, 198 
Spinous processes in scoliotics, 93 
Splint for hip, 364, 373 

ankle fixation, 376 

bow-leg, 377 

infantile paralysis, 380, 384 

knees, 373, 376 

knock-knee, 377 
Spondylitis, 207 

Spontaneous cure congenital hip luxa- 
tion, 58 

fractures, osteogenesis imperfecta, 

67 
rickets, '284 
Spring steel brace, 361 
SprengePs deformity scapula, 21, 24 
Steel brace for Pott's disease, 223 
Steel shoe for calcaneus, 383 
equinus, 383 
equino-varus, 384 
Still's disease, 293 
Subluxations, congenital hip, 60 
patella, 62 
knee, 61 
radius, 63 
ulna, 63 
tarsus, 25, 37 
Subperiosteal hemorrhages, 175, 179 
Subtrochanteric osteotomy, 249 
Suction apparatus of Klapp, 269 
Supernumerary deformities, 10 
Synovitis, acute, 180 
Syringomyelia, fractures in, 69 
Syphilis, bones and joints, 174, 203 
fetal, 65 
in children, 204 
Syphilitic bone pathology, 205 
dactylitis, 204 
fractures, 69 
inherited, 65 

joint suppuration, 65, 205 
osteochondritis, 65 



400 



INDEX. 



Syphilitic pseudo-paralysis, 65 
synovitis, 205 

Tabetic joint disease, 177, 289 
Talipes calcaneus, 25, 315 

calcaneo-valgus, 25, 316 

equinus, 25, 30, 76, 305 

equino-varus, 25, 315 

paralytic, 75, 305 

valgus, 25, 305 

splints, 27, 32, 383 
Tarsal tuberculosis, 260, 263, 268 
Taylor's hip splint, 243 

kyphotome, 339 

spinal brace modified, 350, 354 
Tendon shortening, 116 

sutures, experimental, 317 

transference for paralysis, 315 
spastic paralysis, 77 
obstetrical, Si 

transplantation, see transference, 

Tenodesis, 320 

Tenotomy adductor magnus, 55, 76 

club-foot, 30, 31 

spastic paralysis, 76 

tendo-Achillis, 29, 76 

tibialis anticus, 30 
posticus, 30 
Thomas' caliper splint, 375 

collar, 357 

hip splint, 369, 372 

knee splint, 373, 374 
Thorax, congenital deformity, 18, 20 

in scoliosis, 93 
Toe deformities, acquired, 166, 168 
Total scoliosis, 97 
Torticollis, 323 

acquired, 325 

brace, 356 

congenital, 323 

spasmodic, 323 

symptomatic, 324 

tenotomies, 326 

transitory, 325 

treatment, 325 
Traction hip splint, 364 
Transverse processes, scoliosis, 92 
Traumatic necrosis of bone, 180 
Traumatic periostitis, 179 
Trendelenberg's tests, 44 
Treatment, congenital hip dislocation, 

47,58 
spina bifida, club-foot, 70 



Treatment, complication of Pott's, 224 
flat-foot, 159 

infantile paralysis, 310, 321 
lateral curvature, 113 
round back, round shoulders, 143 
Tubby 's operation, 77 
Tuberculin, 218 

Tuberculosis about hip, 230, 249 
ankle, 260, 263 
Bier's treatment, 267 
bones and joints, 174, 207 
congenital, in animals, 65 
congenital, in man, 65 
elbow, 265 
knee-joint, 250, 260 
hip, 230, 249 

pulmonary, in scoliosis, 94 
sacro-iliac, 226 
shoulder, 263, 265 
spontaneous fracture in, 69 
tarsus, 261, 263 
wrist, 267 
Tuberculous ostitis, vertebral, 208 
Tubular hip splints, 372 
Tumor albus, 250, 260 

arthrectomy, 256 
clinical history, 252 
correction of flexion, 257 
diagnosis, 253 
forcible straightening, 258 
flexion, 253 
joint drainage, 256 
operations to straighten, 259 
pathology, 250 
plaster bandages, 258 
removal of early foci, 255 
resection of knee, 255 
subluxation, 253 
symptoms, 251 
Thomas' splint, 373 
treatment, 254 
venous stasis for, 269 . 
Twists of face and skull, 85 
Typhoid spine, 199 

Ulna, defects of, 3 

Unilateral variations of spine, 14 

Valgus shoe, 382 
Variations, spine, 12, 16 

cervical, 12, 18, 16 

dorsal, 12, 16, 18, 19 

lumbar, 12, 14, 17 

ribs, 12, 13, 15, 19 



INDEX. 



40I 



Variations, sacral, 13, 14, 16, 18 
Varus shoe, 385 

Vertebra, anomalies of a, 12, 14, 16 
cervico-dorsal, 16 
dorso-lumbar, 16 
half sacral, 16 
lumbo-sacral, 14 
Vertebrae, fused, 14 
in scoliosis, 90 

oblique, torsion, lozenge, 90 
wedge, rotation, apex, 90 
Vertebral anomalies, 12, 14, 16 
arches, 91 
pedicles, 92 
tuberculosis, 207 
Villous arthritis, 183 

Walking in club-foot, 26 

Wedge removal for club-foot, 27, 35, 

37 
vertebrae, 90 
White swelling of knee, 250, 260 
arthrectomy, 256 
correction of flexion, 257 
clinical history, 252 
diagnosis, 253 
forcible straightening, 258 
flexion, 253 
joint drainage, 256 
occurrence, 251 
operations, 259 
pathology, 250 
plaster bandages, 258 



White swelling of knee, resections, 

255 
removal early foci, 225 
subluxation, 253 
symptoms, 251 
Whitman's reduction subluxated 
knees, 313 
stretcher frame, 221 
Wire chin rest, 354 
Wolff's method correcting club-feet, 

34, 343 
Wrenches for club-foot, 34 
Wrist, tuberculosis of, 267 
Wrist drop, spastic paralysis, 77 
Wullstein's treatment, scoliosis, 137 
brace, 363 

X bein, knock-knee, 279 

X-rays, congenital dislocation hip, 46, 

5°, 52 
deformity, spine, 17 

thorax and spine, 20 
club-foot after removal astragalus, 

36 
chondrodystrophia, 67 
bow-leg, non-rhachitic, 151 
osteomyelitis, 192, 195 

chronic, 193 
syphilitic periostitis, 204 

eburnation, 204 
sacro-iliac disease, 227 
hip disease, 242, 248, 249 
bow-leg, 274 



26 



